P1949 Lybrook Rd• i DAME COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
'(Ground Absorption'Sewage.Disposal System.- G'.S.'Chapter 130 -Article 13C)
OWNER OR CONTRACTOR ' . l f) DATE Q PERMIT'
LOCATION ' ; ,�- .. ,e,y N�
1949&,_.
S_;. R. NO.
SUBDIVISION NAME LOT N0: SECTION OR BLOCK NO.
HOUSE MOBILE HOW BUSINESS 13.
+/ House•Trailer 800 Gal. 400 Sq. Ft.
N0. BEDROOMS. NO. BATHROOMS Two Bedroom House 800 Gal. 600 Sq.'Ft.'
GARBAGE DISPOSAL UNIT YES ❑' NO Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES. N0
:SITE -SUITABLE YES M NO ❑ ,-
SIZE OF. TANK ...gal...
NITRIFICATION FIELD .sq: ft. f�
DEPTH OF STONE IN -
L4 n
WATER SUPPLY:" Individual Public ❑ � �F�° ����.
'.:IMPROVEMENTS -PERMIT BY ' INSTALLED' Bt:
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DAVIE COUNTY HEALTH DEPARTMIENT
P. O. BOX 57
HOCKSVILLE, N. C. 27028
(7 04) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME DATE ISSUED
ADDRESS e/ /,2'y, ,, % ® /7PERMIT N0. �' Z Z
,.27- i- /—, T 1'rte —
Explanation of charge
91
AMOUNT DUE , ""SANITAR"IAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT/.
DAVIE COUNTY HEALTH DEPART;MNT
PERCOLATION TEST RESULTS
DATE QbSZ&
LOCATION .S'
MIDINGS: HOLE NO.
4
5 _
CO1 ii✓iENTS
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By:
LOT DIAGRA,^4
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