P1928 Country LnDAVIE 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 id jr IV 1f DATE c�/j PERMIT
pp N° 1928
LOCATION} "•. r_r...,?.i .r 1 r t.:.:Y C/ ,
"r S.R. NO.
SUBDIVISION NAME LOT NO. 91:CTION OR BLOCK NO.
s
HOUSE p . MOBILE HOME p BUSINESS
NO. BEDROOMS / NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑,,��` NO
El d
AUTO. DISHWASHER YES NO ❑
AUTO. WASH. MACHINE YES 0, NO ❑
SITE SUITABLE YES t2 NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
DEPTH•OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY 1 /_iG.�',f
CERTIFI
(8/16/73)
LOT. AREA
I
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
TE OF COMPLETION By °- t_ ?1 0//
Date
*Construction must comply with all lother applicable State and local regulations
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DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N.. C. 27028
(7 04) 634-5985
Statement for Septic Tank Improvement Permits
and/or'Site Evaluations
NAME DATE ISSUED
ADDRESS 11- %t !, �` / � V PERMIT NO. -�-�- —
'1.f '
Explanation of charge
AMOUNT DUE SANITARIAN r �1
PLEASE REMIT THE ABOVE AMOUNT ON RECEIP OF THIS STATEMENT.