P2571 Boxwood Church RdDAVIE COUNTY HEALTH DEPARTMENT
r�..; IMPROVEMENTS PERMIT AND CERTIFICATE, OF COMPLETION '
*Ngte: Issued in Compliance with G.S. of North, CaroI'L Chapter 130—Article 13c.
I 1 Permit Number
Name %,' �i/,x� ��
Date
Location t !�1"/.. tl�'�'" ��, Jl.trr / •,'i
Subdivision Name :IjI Lot No. �' Seca or Block No.
Lot. Size .f �►`�' House IiIM6bile Home _ Business Speculation
No, Bedrooms No. Baths
�_ No. in. Family Ii
Garbage Disposal YES ❑ NO. -p--""
_ Specifications: for System:.
Auto Dish Washer YES ❑ NO ❑r
Auto Wash Machine YES IID NO p
Type Water Supplylit
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
j Improvements permit by
*Contact a representative of the Davie County HeIalth Department for final inspection of this. system between 8:30-
9:30 A.M. or 1:00-1:30 P:M on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: i?j System Installed by' 1�c"ST
Certificate of Completion Y�CL.., Date I.2 02 Fb
'The signing of this certificate shall Indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, buYslall,.in NO way betaken as a guarantee that the system will function
satisfactorily for any given period of time. �II
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATEf
NAMES
LOCATION
FINDINGS:
1.
2.
3.
4.
S.
6.
HOLE NO.
COM NTSt
Ey: ( f 7
LOT DIAGRAM
�J
i
-6
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P. 0. BOX 57
MOC&SVILLE, N.C. 27028-
(704)
7028(704) 634-5985
Statement /for Septic Tank Improvements Permits and/or Site Evaluations
NAME f'2�<� l.� y DATE &IA41i
ADDRESS &y-n� - PERMIT 140 12Z
EXPLANATION OF CHARGE 41&Lzj1f
MOUNT DUE SA14ITARIAN
PLEASE REMIT THE ABOVE A14OUNT ON RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.