P2284 Hwy 64EDAVIE 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 moi% � `%., �;�` ; '�•�`' �Date 2284
Location i; Z% `_ 71,!,
J• i
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _! Business Speculation
No. Bedrooms -% No. Baths No. in Family
Garbage Disposal YES ❑ NO pSpecifications for System:.-
Auto
ystem:Auto Dish Washer YES ❑ NO p—'"r
Auto Wash Machine YES [D—NO C]
Type Water Supply
*This permit Void if sewage system described below is 'ot installed within 36 months from date of issue.
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T'
Improvements permit by ✓5��„
*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
Certificate of Completion G/� Date
j
*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.
r
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE- �d
LOCATION
FIlIDI14GS :
1
K
HOLE NO.
PdPn/ /d�.'/
0
LOT DIAGIM
1
COD M MTS
D
2
Dy:'R
D
2
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMEITTAL HEALTH SECTION
P.O. BOX 57
MOCKSVILLE, N.C. 27028
(704) 634-5985
STATEMENT FOR SEPTIC TANK IMPROVEMENTS PERMITS AND/
OR SITE EVALUATIONS 00 i
NAME f j/ri� � DATE �� T�
ADDRESS`/ / PERMIT NO.
EXPLANATION OF CHARGE
AMOUNT DUE SANITARIAN,
PLEASE REaMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEME14T.
*NOTICE: Evaluation (s),can'not be completed until payment is received.
Imp rovements,Psrmi"t(s) can not be issued until payment is received.
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