P2395 Pinebrook School Rd=. DAVIE 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' C. VVk C lrs OJil-A C- Date11
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Location
Subdivision Name
Lot Size
Lot No
House -'� Mobile Home
No. Bedrooms -Q No. Baths
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
YES 0 NO p --
YES 0 NO ❑
YES 0 NO C0
IC -11
No. in Family —
Sec. or Block No.
Business Speculation
Specifications for System: R01c�
1
*This permit Void if sewage system described below -ism' of installed within 36 months from
01
of issue
1
Improvements permit by
s
*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
k,)VO (W 0-
GQo-Fi s
Certificate of CompletionDate
*The signing of this certificate shall indicate that the system describeW 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
PERCOLATION TEST RESULTS
DATE.
NAl,fE �R2.e C:/�'e/ti
w -S 27103
LOCATION &J, ,W P. -.n 6 ak .Cel, -'C
FINDINGS: HOLE NO.
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a.
3.
4.
S.
6.
COMMENTS
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DAVIE COUNTY HEALTH DEPARTMENT
ENVIROIIMEIITAL HEALTH SECTIO14
P.O. BOX 57
MOCKSVILLE, N.C. 27028
(704) 634-5985 j
STATEMENT FOR SEPTIC TANK IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NAME C .,\es k-A,AeDATE S!/77
ADDRESS4.7.35 - f'n,l t� `��qY �',rt�� PERMIT NO. 75--
EXPLANATION OF CHARGE
AMOUNT DUE c
_ 2 Q.
SANITARIAN,.
PLEASE REMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.