P1509DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTORDATE PERMIT
LOCATION J\
SUBDIVISION NAME
S. R. NO.
LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME ❑ BUSINESS
NO. BEDROOMS NO. BATHROOMS ,
GARBAGE DISPOSAL UNIT YES ❑ NO ❑
AUTO. DISHWASHER YES ❑ NO ❑
AUTO. WASH. MACHINE YES ❑ NO ❑
SITE SUITABLE YES ❑ NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY
1509
House Trailer
800
Gal.
400
Sq.
Ft.
Two Bedroom House
800
Gal.
600
Sq.
Ft.
Three Bedroom House
900
Gal.
900
Sq.
Ft.
Four Bedroom House
1000
Gal.
1200
Sq.
Ft.
INSTALLED BY ;
CERTIFICATE OF COMPLETION
By /� ( _ Date
(8/16/73) *Construction must comply with 11 other applicable State and local/reg`ul tions
LOT AREA
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
HOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME DATE ISSUED' -7 �>
ADDRESS PERP9IT N0.
Explanation of charge J.
AMOUNT DUE iti f SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.