612 Cornatzer RdDAVIE 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 L� ,�^. t t t Date
Location i i1
Subdivision Name
Lot No
Sec. or Block No.
Lot Size -w�J f � House ' Mobile Home _ Business Speculation
f
No. Bedrooms > No. Baths `' No. in Family
Garbage Disposal YES p NO p�-
Specifications for System:
Auto Dish Washer YES p NO p -
Auto Wash Machine YES p NO
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by r CJ f
- -,
*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 ' r=raLTi /I-/
C�r
Certificate of Completio,,��-��4' �ZDate-7 Cl
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*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 DEPARTMEWT
PERCOLATION TEST RESULTS
DATE
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FINDINGS: HOLE NO. COMMENTS
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2 501
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LOT DIAGRAM
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By:
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DAVIE COUM HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P.O. BOX 57
MOCKSVILLE, N.C. 27028 f,
(704) 634-5985
STATEMENT FOR SEPTIC TANK IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NAM (,' IND& SM%T14 DATE f SR' 1?0
ADDRESS IzT. z7- A I PERMIT NO.7"i Y*7
{�yZ,.oCkS�+ccs N► � .
EXPLANATION OF C1WGE l S I TL ! V A L V A17 ` %--- � � I � P� Vf4-^
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Ai`20UNT D m+oo ''5ANITARIAN
PLEASE REMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
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*NOTICE: Evaluation(s) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.