P2578 Hwy 601SDAVIE 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 tit �., f? .�-� �,, - ��, Date t - - l o - r r1 G7
1
Location d r,, i -, �l •r 1�
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home ! % Business Speculation
No. Bedrooms =' No. Baths I No. in Family
Garbage Disposal YES 10 NO ❑. Specifications for System:
Auto Dish Washer YES ❑ NO fl,
Auto Wash Machine YES 0- NO ❑ `J I
Type Water Supply {..,r t l f-' .�/ f' ,� _ �:- /;✓
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
i
Improve/ts permit by - -
*Contact a representative of the Davie County Health Departrpdnt 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 Numbdr: 704=634-5985. __- -�l
Final Installation Diagram:yS stem Installed b����
Ss1C �5�%�� y zvl
Certificate of Completion - l�-�-- Date
'The signing of this certificate shall indicate that the system descnbed,above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way betaken as a guarantee that the system will function -
satisfactorily for any given period of time.
N
1�
DAVIE COMITY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P. 0. BOX 57
MOCKSVILLE, N.C. 27028-
(704)
7028(704) 634-5985
Statement for Septic Tank Improvements Permits and/or Site Evaluations
NAME - , h-` DATE 1';)L - %a- qn
ADDRESS Qk- q gtjQ-3(, PERI -11T 110. a� 7
EXPLANATION OF CHARGE
AMOUNT DUE o• &1C-')
SANITARIAN� Q,
PLEASE REMIT THE ABOVE A14OUNT ON RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until paynent is received.
Improvements Permit(s) can not be issued until payment is received.