P2593 Rainbow RdDAVIE COUNTY HEALTH DEPARTMENT
f IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name - Date G
_ e
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
_ No. Baths No. in Family
YES ❑ NO ❑ Specifications for System:
YES ❑ NO C]
YES ❑ NO -❑
*This permit Void if sewage system described below is not installed withi6 36 months from date of issue.
Z
Improvements permit by,.--'
*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.-1
Final Installation Diagram: 1 System Installed•by
Certificate of Completion ` / 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.
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE )
NPI E /c
LOCATION
FINDINGS: HOLE NO.
2.
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5.
6.
LOT DIAGRAM
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DAVIE COUr1TY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P. 0. BOX 57
MOCKSVILLE, N.C. 27028-
(704)
7028(704) 634-5985
State nt for Septic Tank Improvements Permits and/or it Evaluations
NAME P ,-?DATE DATE / 6-e/
ADDRESS PERMIT 140.
EXPLANATION OF CHARGE�t.( •E'i�/ �'1 �" 1L
A14OUNT DUE SA14I TARIAN y
PLEASE REMIT THE ABOVE AMOUNT ON 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.