P1216' DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System.- G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR- DATE PERMIT
"
LOCATION , • W
21
S.R. NO. I
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
P
HOUSE [ MOBILE HOME U BUSINESS ❑
NO. BEDROOMS NO. BATHROOMS !�
GARBAGE DISPOSAL UNIT YES ❑ NO
AUTO. DISHWASHER YES ❑ NO ❑
AUTO. WASH. MACHINE YES C NO ❑
SITE SUITABLE YES ❑ NO ❑
SIZE OF TANK l gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
I
WATER SUPPLY: Individual ❑ Public ❑;,".
IMPROVEMENTS PERMIT BY
i
House Trailer 800 Gal. 400 Sq. Ft.
Two Bedroom House ,$Ao-Ga,k!,
Three Bedroom House :'9.0D..,Gal.t 900, Sq.. Ft.
Four Bedroom House 1000 Gal. 1200 Sq. Ft.
�..y
J p-r
INSTALLED BY
CERTIFICATE OF COMPLETION By Q f� DateSIM_7
(8/16/73) *Construction must compAy with all other applicable State and local r gulations
LOT AREA
T
1 t.
i
}