P1426 Jack JohnsonDAVIE 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 M r N? 1426
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME ❑
BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS NO. BATHROOMS
Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑
NO QA
Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES Q�
NO [?I
Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YESC(
NO ❑
'--SITE SUITABLE YES En
NO ❑
SIZE OF TANK - gal.;-4,`,�''�y"
NITRIFICATION FIELD
sq. ft.
DEPTH OF STONE IN LINES:
❑
WATER SUPPLY: Individual
Public
IMPROVEMENTS PERMIT BY
INSTALLED BY �c�+u�... S : �• Co .
CERTIFICATE OF COMPLETION By
- - Date 11-11-77'
(8/16/73) *Construction must Amply with all
other applicable State and local regulations
LOT AREA
i
1
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME3ne� � UI�r�Sv. DATE ISSUED
ADDRESS PERMIT NO. _
i.cln�crcl n �'.. �gOa 5
Explanation of charge
AMOUNT DUE CA SANITARIANSkt Y1'1
t
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.