4264 Hwy 158 (2)DAVIE COUNTY HEALTH DEPARTMENT SEPTIC TANK PERiMIT
Tto, of Bedrooms Date 3 - __ 2- —
1 •: 1 ✓
:'..'his pe.r:ait is granted to ,L � . / - for the insta11 t.'or. of a septic tank_
at the residence of &Z" -Z _-� Address 411x .� bb r_
Building Contractor Address
Ser)t:ac T4ank S-c:ecifieations: Length _ Width-- Depth_— Capacity Y Gal,
IMIanufacturerI s Name t- Address -
!!o, of linea^ L- width. -4'i.n. Tdtal Length _ ft. L'o. of Sq. Ft.
'I'jpe of fa- Iter material Total tons used
P��.n4mLmia RequireinLents: House Trailer Tank Cap. 800 Sq. ft. line ! 00
Two-bedroom house 800 600
Three-bedroom house 900 900
Eo one shall install a septic tank in Davie County without a permit from the Health Officer
or hj.s agent.
Date of 'in•al approval Signed: _
Sanitarian
I h eren cez•tify that the above septic tank has been installed according to specifications.
Signed:
Septic Tank Contractor
Note: Make sketb',r of disposal system on back of sheet and :ail to Health Center, Mocksville,
51
/h ASV