P1601 Cedar Grove Church RdDAVIE 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 C!1 i� i!) : I /�� DATE YPERMIT �+
LOCATION C. �' ; . c' ; ,i : 4.r; �r i . i �, : z' (. 1\ 9 1 U01
,
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE p MOBILE HOME ❑ BUSINESS ❑
NO. BEDROOMS NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO Df
AUTO. DISHWASHER YES ❑ NO Q
AUTO. WASH. MACHINE YES Qr NO ❑
SITE SUITABLE YES El NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY
CERTIFICATE
(8/16/73)
LOT AREA
House Trailer
Two Bedroom House
Three Bedroom House
Four Bedroom House
800
Gal.
400
Sq.
Ft.
800
Gal.
600
Sq.
Ft.
900
Gal.
900
Sq.
Ft.
1000
Gal.
1200
Sq.
Ft.
INSTALLED BY,yyt,��ijj
OF COMPLETION By-
�{_,,,,�/�/ Date `����/�90
*Construction must comp fy with all other applicable State and local regulations
1
,00 X2 Xi A4//
------------
AL
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations /
NAVE �i� �j,`'.�1�� yl DATE ISSUED
ADDRESS 3, L416 PERF+:IT N0.
Explanation of charge 4' �✓�- -�Y �i i
AMOUNT
PLEASE REASIT
DUE / ,
THE ABOVE AMOUNT
SANITARIAN,.
ON RECEIPT OF THIS STATEMENT.