P1909 Gladstone RdDAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System --G.S. Chapter 130-Ar.ticle 13C)10 '
.•
OWNER .AR -CONTRACTOR j r.�,',�� :;� f ; .�;^ , f DATE `7�'i%r.�; PERMIT
r I
LOCATION Ir `IPJ /• 1 f i; . �' f. Fr f NO 1909
f'' / -j% :r t r
t S.R. NO.
SUBDIVISION NAME" ' t/.5 LOT NO. SECTION OR BLOCK NO.
.t
HOUSE Q" MOBILE HOME BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS NO. BATHROOMS 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 YES ❑ NO
SITE SUITABLE YES ❑ NO , r r" f
• SIZE OF TANK . � ga 1. r�-� f„G�''�
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual „❑ Publ�c "
IMPROVEMENTS PERMIT _BY ►-t.�'/;� �-fXIV INSTALLED BY
CERTIFICATE OF COMPLETION By Date
(8/16/73) *Construction must comply with all other applicable State an local regulations
LOT AREA i
DAVIE COUNTY HEALTH DEPARTMENT
P. O. BOX 57
HOCKSVILLE, N. C. 27028
(704) 634-5985
L
1-
1� �
U"
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
i
NAMEDATE ISSUED
ADDRESS ,telt/ PERMIT NO.
M.,/, /�<,, /& 4.24 A _
Explanation of charge__
AMOUNT DUE � SANITARIAN
PLEASE REMIT THE ABOVE AIIOU14T ON RECEIPT OF THIS STATEMENT.
1