128 Camellia Ln (2)y_ DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
-- .� Permit Number
Name d �Y �t,� 1+ "�)1 L + t ! �'- 1 ? Date
Location _jJ
Subdivision Name
Lot No. Sec. or Block No
Lot Size �f - House Mobile Home.
No. Bedrooms r~' - No. Baths No. in Family _
Garbage Disposal
YES
❑
NO 0
Auto Dish Washer
YES
❑
NO ❑
Auto Wash Machine
YES
❑
NO .❑
Type Water Supply u %
-' Business Speculation _
Specifications for System: -�
*This permit Void if sewage system described below is not installed within 36 months from date of issue
Improvements permit by -
a
*Contact a representative of the Davie County Health 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:
System Installed by
Certificate of Completion Date
"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, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT- AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name-���1 L. iN l C.(.,� Date�°
�'�
72
location (�(� % )p1 iU/i (� � (�. / f?r��l.ox
C. z. (_
Subdivision Name
Lot No. Sec. or Block No.
Lot Size House Mobile Home ^' Business Speculation
No. Bedrooms x No. Baths j No. in Family
Garbage Disposal YES ❑ NO [j Specifications for System:
Auto Dish Washer. YES ❑ NO C) ''bo 64(_(00 711-1'ji 1) - L(iX
Auto Wash Machine YES ❑ NO C]
Type Water Supply�,v _—
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by
�
*Contact a representative of the Davie County Health 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:
System Installed byi1'�
Certificate of Completion ,�1 Date
*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, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPART14ENT
PERCOLATION TEST RESULTS
DATE r ��
NAME 'D/,LC?T5 (,,S ` LkA4Z—%>
LOCATION 'DA74t4 E R-- R D 6 O 1 )J. -
FINDINGS:
J
FINDINGS: HOLE NO. COM ENTS
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LOT DIAGR .-I
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DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMEPTTAL HEALTH SECTION
-» P.O. BOK 57
MOCKSVILLE, N.C. 27028
(704) 634-5985
STATEMENT FOR SEPTIC TAMC IMPROVEMENTS PERMITS AND/OR S TE EVALUATIONS
L !�-C - !/-
NAME �� C �S �(iI ��" 0DATE
ADDRESS PERMIT NO. Z 3-7 / Z
EXPLANATION OF CHARGE S r -M r ✓h"2 v/."71 u rj .5
PLEASE REMIT THE ABOVE AMOUNT OF 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.