P1921 Dulin 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 /f�,L �!�F/� DATT'E� �" =.� PERMIT
LOCATION i!'fl�/irlli �'7 /�.1 /f-% rc"'ll�l,/ -..t +w 1\ 1 \9 2 1
SUBDIVISION NAME
OF COMPLETION
By
AT o% AT /Y f�U
LOT NO. SECTION OR BLOCK NO.
(8/16/73) ',
*Construction must comply with
HOUSE Er MOBILE
State and local. regulations
LOT AREA
HOME
E3
BUSINESS ❑
N0. BEDROOMS �,.5 "
N0.
t�
BATHROOMS pC
House Trailer 800 Gal.
400 Sq. Ft.
110
Two Bedroom House 800 Gal.
600 Sq. Ft.
GARBAGE DISPOSAL UNIT
YES
❑
NO ❑ .
Three Bedroom House 900 Gal.
900 Sq. Ft.
AUTO. DISHWASHER
YES
❑
NO ❑
Four Bedroom House 1000 Gal.
1200 Sq. Ft.
AUTO. WASH. MACHINE
SITE SUITABLE
YES
YES
❑
[3NO
NO ❑
❑
,�^ ,r ,r� 1� ,..•� �'�
{ .-' ,� ,+�(, ,•�
SIZE OF TANK
gal.
NITRIFICATION FIELD
sq.' , f t*:
DEPTH OF STONE IN LINES:
F
---�
.WATER SUPPLY: Individual
❑
Public ❑
. r
_
IMPROVEMENTS PERMIT BY
INSTALLED BY
CERTIFICATE
OF COMPLETION
By
AT o% AT /Y f�U
Date
(8/16/73) ',
*Construction must comply with
411,other applicable
State and local. regulations
LOT AREA
110
t
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
NAME - DATE ISSUED
ADDRESSA44 f PERMIT N0./��
Explanation of charge
AMOUNT DUE "co SANITARIAN
PLEASE REMIT THE ABOVE AI40UNT ON RECEIPT OF THIS STATEMENT.