2780 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
2009
Name f �t/)V/)i7 t�. 1�1. h Ill FDate E/
f l 7cP—
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Location d f: 9-«. 11614,112 R", . !i 0
*This.permit Void if sewage system
iescribed below is not installed within 36.months from date of issue..
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;!Improvements permit
*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
Baa 3
!r
i Certificate of CompletionDate 2Z
'The signing -of this certificate shall indicate that the system described above ha/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.
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Subdivision Name '
Lot No. Sec. or Block No.
Lot Size ("
.
House i! `°
I
Mobile Home
Business __ Speculation
._a
No. Bedrooms -
No. Baths f�`'
No. in Familyill
Garbage Disposal
YES E] NO p`J
Specifications for System:
Auto Dish Washer.
YES p` NO p
Auto Wash Machine _
YES p'" NO 0'
j
Type Water Supply
n.,tu �
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�r�G��X e l.P
*This.permit Void if sewage system
iescribed below is not installed within 36.months from date of issue..
ii �' - c:.-�� d..•� 4� 'tel -Cr. ��✓i-E'.,�
Jj} n y r
ii
v L� .7.7
I
!
1.
;!Improvements permit
*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
Baa 3
!r
i Certificate of CompletionDate 2Z
'The signing -of this certificate shall indicate that the system described above ha/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.
...na-..'.." ir:».v$s ..-<.s :+..wi-�k..... ..r,:..: 2 < '.. .,«.....a+3�is-L -_..._ _..rw..-r:r•......a. ' .".F.. .a. lrr.. . .�
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
HOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME
ADDRESS
Explanation of char
J DATE ISSUED 11-7
3 ' PERMIT NO. � O
07�
A140UNT DUE pCQi SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMEN .
A
DAVIE COUNTY HEALTH DEPARTMENT el
S
PERCOLATION TEST RESULTS
DATE /
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6
NAA G
i
LOCATION
FINDINGS: HOLE NO.
Z
3
4
5
LOT DIAGM1
6
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'X\ �5
CODMENTS
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By:
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