P2574 Liberty Church RdDAVIE 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 ,� ,; Date ✓' %'~ .. (.
Location r
it�
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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 Specifications for System:
Auto Dish Washer YES p NO ❑
Auto Wash Machine YES p NO ❑
Type Water Supply
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
r, `
Improvements permit by Ze.- --�
`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 "� J szf-j1L
Certificate of Completion �;fI � , ' Date
*The signing of this certificate shall indicate that the system describ0 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.
DATE
NA14E
DAVIE COUNTY HEALTH DEPART?,LENT
PERCOLATION TEST RESULTS
LOCATION
FINDINGS:
4
HOLE NO. COB24ENTS
LOT DIAGRM-1
I
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By:
Statement for S
NAME J i
ADDRESS
EXPLANATION OF CHARGE
DAVIE COL11ITY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P. 0. BOX 57
MOCRSVILLE, N.C. 27028
(704) 634-5985 / p
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is Tank Improvements Permits and/or Site Evaluations
' _ DATE��r�
PERMIT IJO.,,, � a�
AM0UNT DUE;,,Q - SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT 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.