P2592 Rainbow RdF� y
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 Date�;�
Location
Subdivision Name
Lot No.
Sec. or Block c No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No.. Baths No. in Family
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
YES ❑ NO ❑'
YES ❑ NO ❑
YES Q NO F71
Specifications for System:
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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.
Final Installation Diagram: System Installed by ✓',�;' ,` '' A �f' - `
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Certificate of Completion f �� / Date �%�2A1 /
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*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.
DATE X 11Y
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
LOCATION /,��✓.hAt A�91
FINDINGS: HOLE NO.
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2. Zj P -
S.
6.
LOT DIAGRAM
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COMIENTS
/ �01 XLlc-1 ti
By: o�
A
DAVIE COUNTY HEALTH DEPART^TENT D
ENVIRONMENTAL HEALTH SECTION J
P. 0. BOX 57
MOCKSVILLE, N.C. 27028-
(704)
7028(704) 634-5985
Statenent for Septic Tank Improvements Permits and/or site
Evaluations
NAMf. ( DATES/��
ADDRESS PEPMIT 140.
EXPLANATION OF CHARGE
AE4OUT1'i' DUE ,'-' ,
SANITARIAN�!'�!
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATE.`4ENT.
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*NOTICE: Evaluation(s)--can not be completed until paynent is received.
Improvements Permit(s)--can not be -issued until payment is received.