P22DAVIE COUNTY HEALTH DEPARTMENT
r �(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR' •'• j. .= ' r'_ ' ., DATE PERMIT
-22
LOCATION „ `a' t� r . ' r '.�, <✓ .) €.. s .,
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE MOBILE HOME U BUSINESS ❑
NO. BEDROOMS "� NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES NO ❑
AUTO. DISHWASHER YES Q' NO ❑
AUTO. WASH. MACHINE YES ®r"ANO ❑
SITE SUITABLE YES C NO ❑
SIZE OF TANK ,+ G' : r gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
f
WATER SUPPLY: Individual d`Public ❑
IMPROVEMENTS PERMIT BY ! �V : •;
CERTIFICATE OF COMPLETION
BY—
(8/16/73) *Construction must
LOT AREA
House Trailer
Two Bedroom House
Three Bedroom House
Four Bedroom House
800 Gal. 400 Sq. Ft.
800 Gal. 600 Sq. Ft.
kE900—Gam __....q00--Sq.__Ft:
INSTALLED BY t,A_Lj, `t• C-0 .
Date (a - o - 7y-
ly with all other applicable State and local regulations
4