1116 NC Hwy 801 North�...., 1 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 , ris, x� . f �. r'r ' -- — Date �
Location
Subdivision' Name Lot No. - Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
YES ❑ NO p
YES ❑ NO fl
YES ❑ NO C1
zLL
No. in Family
Specifications for System: f o oo
J x ,+,
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
E
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 Y + YY\ r^
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
ENVIRONM ITAL HEALTH SECTIO14
jh . P.O. BOX 57 (��` ✓ �,�
MOCKSVILLE, N.C. 27028 t�
(704) 634-5985 v AIID
STATE1211T FOR SEPTIC TANK I-MPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NAME .J ir„n�, G�r.�N%i-% DATE—3 —iQ --91
ADDRESS PERMIT NO.��
EXPLANATI014 OF CHARGE_ j. utn.M: iJust +•c 5
A,'�IOUNT DUE :? . SANITARIAN
PLEASE REMIT THE ABOVE P140UNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Iarorovements Permit(s) can not be issued until payment is received.