P1623 Sherlie MyersDAVIE 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 ,;, % :' _ r r. f'% `d1 ,ti" DATE � %� j "i PERMIT
LOCATION N?. 1623
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE p MOBILE HOME Q" BUSINESS
NO. BEDROOMS NO. BATHROOMS I
GARBAGE DISPOSAL UNIT YES ❑ NO Q
AUTO. DISHWASHER YES ❑ NO Q
AUTO. WASH..MACHINE YES ill NO ❑
SITE SUITABLE YES CJ NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD ( sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY % - . );'.:..
CERTIFICATE OF COMPLETION
By
(8/16/73) *Construction must comply
LOT AREA
House Trailer 800 Gal.
Two Bedroom House 800 Gal.
Three Bedroom House 900 Gal.
Four Bedroom House 1000 Gal.
INSTALLED BY
400
Sq.
Ft.
600
Sq.
Ft.
900
Sq.
Ft.
1200
Sq.
Ft.
Date z --7
all other applicable State and local regu ation
t -
'1
i
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
6 7
NAME � uc" ii� �w DATE ISSUED
J r
ADDRESS �� PERMIT NO.
Explanation of charge
AMOUNT DUE
SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.