2767 Hwy 64EDAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
Ground Absorption,Sewage Disposal System - C.S. Chapter 130 -Article 13C)
ER OR OONTRACTOR DATE PERMIT
20CA TION
972
SVBDIVISIO1 NAME
ZJC. BEDROOMS
NO. BATHROOMS
GARBAGE DISPOSAL -UNIT
YES ❑ NO
,6,-[JrO. DISM&SHER
YES NO ❑
AUTO. WASH. MACHINE
YES ®,-• NO [3
SITE SUITABLE
YES ED", NO [3
S-1ZE OP TANK
. gal.
r4:r-rRiFiCAT1.DN FIELb,,,
sq. ft.
]:)F -PTH OF S7014E IN LINES,.,
(,906
WATER SUPPLY: Individual
Public rl
IMPROVEMENTS PERMIT BY
1000
Gal.
NO.
SECTION OR BLOCK NO.
House Trailer
800
Gal.
400
Sq.
Ft.
Two Bedroom House
800
Gal.
600
Sq.
Ft.
Three Bedroom House
"x'06
Gal)
(,906
Sq "---,
-
Four Bedroom House
1000
Gal.
1200
Sq.
Ft.
A�
1/14
Ar
INSTALLED BY
:CERTIFICATE OF COMPLETION Date
*Construction By
(8116/73) must rc4Wy�w�itatl other applicable �State and local regulations
LOT AREA
-0
Phone. (336) - 753 - 6780
Davie County Health Department
Environmental Health Section
P.O. Box 848
210 Hospital Sheet .;
Courier #: 09-40-06
Mocksville, NC 27028
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Fax: (336) - 7.53-1680
Name: &i4 -eh Gh A Phone Number 336- / - p64 ome)
Mailing Address: s hJ EQS� V0 --so9 sWork)
2. R ( Email Address: � � Iy)' nj l( P J O UX K �2 , Kc,
Detailed Directions To Site: Fy ems, ! V I n f• L Cf 1; I I n A i.. _ 1 Fd r .. y r t� QS
Property Address:
Please Fill In The Following Information About The
Name System Installed Under:
Date System Installed
Is The Facility Currently Vacant? YesNo
Any Known Problems? Yes No If Yes, E
TING Facil!!'ty: /\\. — - -202-'u
ort Tnol �JNer) I
Pype Of Facility: L TGlq IC
:)Number Of Bedrooms:Number Of People:
If Yes, For How Long?.
Please Fill In The Following Informal* About The NEW Faci ity: R Off C�
Type Of Facility: {/� Q��� �,,Q and /lg *U lier Or Bedrooms: Number of People
Pool Size: Garage Size: 1 Oilier:
jRequested By: /n /I �n� /
YQ` Ora s /I /I R5 Date Requested: /
For Environmental Health Office Use Only
Approved Disapproved
Environmental Health Specialist.
of this form by the
in no way intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will fuuCt iL-n properly for any given period of time.
Payment: Cash Check Money Order # Amount:1
Paid By: Received By:
Account #: rm.,,..,.e 1
(314)
175
C,
(3.44A)
2327
(205)