P2313 Hwy 801NDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NoteAssued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
R - - - Permit Number
Name �' �; Date
Location/ rii:✓.,', r r,, '%--
r
Subdivision Name Lot No. Sec. or Block No.
Lot Size -
�{ ``! HnusP J MnhilP HnmP
No. Bedrooms
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
W,
No. Baths % No. in Family.
YES ❑ NO p'"—
YES ❑ NO ❑
YES M NO ❑
r ,
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Business Speculation
Specifications for System:
r, -
Type Water Supply
ermit Void if sewage system described below is not installed within 36 months from date of issue. '
'This,`
P 9 Y
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.
7
01
Improvements permit by
`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
I j /f
Certificate of Completion Date
*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.
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C. 27023
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site,Evaluations
NAME &ZZ CI-40�?e DATE ISSUED
ADDRESS ��t ��� PERMIT NO.
i.�.
Explanation of charge
AMOUNT DUE SANITARIAN/%
PLEASE REMIT THE ABOVE AMOUNT ON RECE'IRT OF THIS STATEMENT.
DAVIE. COUI TY HEALTH DEPARTMNT
PERCOLATION TEST RESULTS
DATE
LOCATI014
LOT DIAGWL i
f
b
HOLE 140.
1
4
4
5
0
CO.IFIMITS
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