P2435 Cornatzer Rd" 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 ,I � i�' :-t a +./�- T..l
Date
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Location - �_<- ! �•.� ,._r., ,�f:, , f: <<
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Subdivision Name Lot No. Sec. or Block No.
Lot Size r ,c House °' Mobile Home — Business Speculation
No. Bedrooms , No. Baths No. in Fancily
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
YES ❑ NO ❑
YES ❑ NO C)
YES ❑ NO ❑
Specifications for System: o-')
6
'This permit Void if sewage system described below is not installed within 36 months from date,of issue
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Improvements permit by
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*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
Ce ' icate of Completion li ' /� i ��f�� t --Date`�" ` t
*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 DEPART?,JENT
PERCOLATION TEST RESULTS
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FINDINGS:
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DAVIE COUM HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTIO14 p
,.i_. P.O. BOX 57 �cX' w 110
MOCKSVILLE, N.C. 27028 SI'S'
(704) 634-5985
STATEMENT FOR SEPTIC TANK IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NAMEDATE
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ADDRESS l�+t� . ���� GbPERMIT NO.
�' L PAPA g" 2-7 O l Z-_
EXPLANATION OF CHARGE / 571 -T
AMOUNT DIP 2.--0o "
VAtoe;Tio �7
l t ,17 .S f f iZ Yri 1.1
SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Iamrovements Permit(s) can not be issued until payment is received.