P112272 Liberty Church RdE:----::
DAVIE COUNTY HEALTH DEPARTMENT
Jwner/Occupant �yy,-yy. �re (4
Address
SEPTIC TANK PERMIT Date //—(,Z7, — ?
To: J.I.J Jam. I,• •
Address,,��
Building Contractor Address
Cal. d U Manufacturer's Name Address��/dam--t!,tc�.
No. of lines �_ Width �� in. Tota length /Do � ft. No. sq. ft. �Icb
Type of filter material �'�oiJ/' Total tons used /<�
------T-----
Minimum REquirements: [louse Trailer Tank cap. 800 Sq. ft. line 400
Two-bedroom house 800 600
Three-bedroom house '900 900
No one shall install a septic tank in Davie County without a permit from the Health Offic
or his agent.
Date'of Final Approval
Signed:
Sanitarian
I hereby certify that the above septic tank has been installed according to specification
Signed: 1
617 Septic 19RContra
Note: Make sketch of disposal system on backfof sheet and mail to Davie County Health
Center, Box 57, Mocksville, North Carolina 27028.