P1504 CooleemeeDAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER O.;, CONTRACTOR DATE is ,
PERMIT
LOCATION ` 11 t: r';: ri"�„,,ft 1\� 1504
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE g] MOBILE HOME ❑ BUSINESS
NO. BEDROOMS
GARBAGE DISPOSAL UNIT
AUTO. DISHWASHER
AUTO. WASH. MACHINE
SITE SUITABLE
SIZE OF TANK
NO. BATHROOMS
YES
❑
NO
❑
YES
❑
NO
❑
YES
❑
NO
❑
YES
❑
NO
❑
ga 1.
1200
Sq.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑
House Trailer
Two Bedroom House
Three Bedroom House
Four Bedroom House
Crjc/ - el , tell -
800
Gal.
400
Sq.
Ft.
800
Gal.
600
Sq.
Ft.
900
Gal.
900
Sq.
Ft.
1000
Gal.
1200
Sq.
Ft.
IMPROVEMENTS PERMIT BY �, %� r,�r.�t) INSTALLED BY ��c...,., a I ' Cv
V- -- -- ------ --
CERTIFICATE OF COMPLETION
By ;' Z F ) l i �. , to Date
(8/16/73) *Construction must compAy with all other applicable State and local regulations
LOT AREA
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~ DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57 7111Sf7�
MOCKSVILLE, N. C. 27028
(7 04) 634-5985 k,l ;(J
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME �� �t �. DATE ISSUED �S %
ADDRESS ��% �h, S PERMIT NO.
Explanation of charge
AMOUNT DUE
PLEASE REMIT THE ABOVE AMOUNT
SANITARIAN
ON RECEIPT OF THIS STAWMENT.