P2615 Jericho Church RdDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTSPERMIT AND CERTIFICATE OF COMPLETION
`Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Name '
Location
Permit Number
Date _..0
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 :p NO p " Specifications for System:
Auto Dish Washer YES p NO p
Auto Wash Machine YES -O_ NO p
Type Water Supply - _
*This permit Void if sewage systen'described below is not installed within 36 months from date of issue.
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Improvements permit by
*Contact a representative of the0avie 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.
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Final Installation Diagram: System Installed by �l� V i LA_(\V-T)
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Certificate of Completion ,a! 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.
y
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATIONVTEST RESULTS
-71 DATE
NAME
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LOCATION___6k
FINDINGS: HOLE NO.
X.
Y
S.
5.
LOT DIAGRAM
ARM
C01,24ENTS
A
By:
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
_..:. P.O. BOX 57
a,
► MOCKSVILLE, N.C. 27028
(704) 634-5985
STATEMENT FOR SEPTIC
NAME .�
ADDRESS
EXPLANA
PEIL14ITS AND/OR SITE EVALUATIONS
DATE
PERMIT NO.!
AMOUNT DUE r SANITARIAN
PLEASE RE:tiIIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
_Irrorovements Permit(s) can not be issued until payment is received.