1930 Liberty Church RdAtW 1104 400"t
DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorpt on Se a D, osal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR y'r� < L�li'�� DATE PERMIT
O
LOCATION l 8 5
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
tl
HOUSE MOBILE
HOME
❑
BUSINESS
NO. BEDROOMS
NO.
BATHROOMS
GARBAGE DISPOSAL UNIT
YES
❑
NO
�S
L
AUTO. DISHWASHER
YES
❑
NO
®'
AUTO. WASH. MACHINE
YES
E
NO
❑
SITE SUITABLE
YES
❑
NO
❑
SIZE OF TANK
gal.
NITRIFICATION FIELD
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual
IMPROVEMENTS PERMIT BY
sq. ft.
Public ❑
House Trailer 800 Gal. 400 Sq. Ft.
Two Bedroom Houseal. Ft.
Three Bedroom House t, 900 Ga 900 Sq.
Four Bedroom House 1000 Gal. 1200 Sq. Ft.
INSTALLED BY
CERTIFICATE OF COMPLETION By Date c,�_
"(8/16/73) *Construction must comp with all other applicable State and local regulations
LOT AREA
Ar 4L�u -"'
'- DAVIE COUNTY HEALTH DEPARTMENT '
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR �� ' ',' :`'. i t' /" C"' DATE PERMIT
LOCATION
' S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE [}+, MOBILE HOME p BUSINESS
r
NO. BEDROOMS NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO ET
AUTO. DISHWASHER YES ❑ NO [�
AUTO. WASH. MACHINE YES ( NO ❑
SITE SUITABLE YES ❑ NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ,,�M Public ❑
IMPROVEMENTS PERMIT BY
House Trailer 800 Gal.
Two Bedroom House -&00-.Gal.
Three Bedroom House ;900 Gall.
Four Bedroom House 1000 Gal.
INSTALLED BY ti%i(iil ✓prt.5 .�Y /
Alm
400 Sq. Ft.
600_.Sq. -Ft.
Sq. ,Fr.
1200 Sq. Ft.
CERTIFICATE OF COMPLETION Bt" J / etIe
Y--�� � Date �i �9
" " % 4'
(8/16/73) *Construction must comp with all other applicable State and local regulations
LOT AREA Gr eu 4
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ea CL ot 7V
---PARTMENT
f (SEPTIC TANKIMPROWAEMS PRRIT
AND CERTIFICATE OF COMPLETION:
} } Ground Absorpti Sewage -Di osaI.System - G.S.hapter 130 -Article 13C)
C ;
OWNER OR CONTRACTOR ' �'
DATE:' PERMIT NO.
F,; F LOCATION
S.R. N0.
-;`'SUBDIVISION NAME ' ' "' LOT ,NO
SECTION OR BLOCK N0. ^ .
•:,
MOBILE HM%IE `BUSINESS
LOT' AREA
NO.BEDROOMS ..�3_ NO. BATHROOMS F\
'i r.,ARBAGE DISPOSAL UNIT °''YES CI NO
_ AUTO.' DISHWASHER ':YES Q '-: -NO
;
AUTO. • MASH.' MACHINE YES �� NO �1
'i',`SITE SUITABLR YES ,'NO
s ;:SIZE. OF TA2nC
;�
' NITRIFICATION FIELD
t
OF STONE IN LINES
HATER SUpPLXs' Individual Q Public d 1
IliPROYEPfENTS PERMIT BY
-INSTALLED BY
=; CERTIFICATE, -OF COMPLETION BY
DATE '
s (8/16/73) "*Construction musts ly.with all
:�
other-applicable:'State and local regulation's
k`�
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