P195 Chinquapin RdDAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absor ti n,ew/a Dist osal System - G.S. Cha to 130-A t' le 13C
OWNER OR CONTRACTOR p s f f ,� � S '`t C' '�"y DATE �C � A"5 ERMIT
O
LOCATION 1� �0�.►� +� t f C2 + •
SUBDIVISION NAME
S. R. NO.
LOT NO. SECTION OR BLOCK NO.
195
HOUSE ❑ MOBILE
HOME A
BUSINESS ❑
a
House
u1�
Sq,—Ft,
N0. BEDROOMS
N0.
BATHROOMS
dram House
Two Bedroom House
•-.rrJ
GARBAGE DISPOSAL UNIT
YES
❑
NO ❑
Three Bedroom House
900 Gal.
900 Sq. Ft.
AUTO. DISHWASHER
YES
[:1
NO 13Four
Bedroom House
1000 Gal.
1200 Sq. Ft.
AUTO. WASH. MACHINE
YES
0
NO [3
;-R,l';
14� r
SITE SUITABLE*
YES
❑
NO ❑
SIZE OF TANK t'S
gal.
ft.
NITRIFICATION FIELD
sq.
DEPTH OF STONE IN LINES:
! Q 0
WATER SUPPLY: Individual
❑
Publics. ❑
). #
IMPROVEMENTS PERMIT BY
r
INSTALLED BY
CERTIFICATE OF COMPLETION By
(8/16/73) *Construction must C156y with all other applicable State and loca egdiations
LOT AREA?
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