P1639 Dwight SchulerDAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvem;nts %Permit and Certificate of .Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
�, OWNER% OR CONTRACTOR r'. DATE %<' % ���% PERMIT
LOCATION
S. R. NO.
SUBDIVISIOWNAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME ,. BUSINESS [
NO. BEDROOMS f NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO
AUTO. DISHWASHER YES [3 NO ❑
AUTO. WASH. MACHINE YES C5 NO ❑
SITE SUITABLE YES ❑ NO ❑
SIZE OF TANK /; (i gal.
NITRIFICATION FIELD sq. ft.
DEPTHOF $TONE IN LINES: �w
WATERSUPPLY: Individual- ❑ Public [3IMPRO MENTS/1PERMIT BY
HouseTrailer
Two Bedroom House
Three Bedroom House
Four Bedroom House
1639
800
Gal.
400
Sq.
Ft.
800
Gal.
600
Sq.
Ft.
900
Gal.
900
Sq.
Ft.
1000
Gal.
1200
Sq.
Ft.
INSTALLED
CERTIFICATE OF COMPLETION By C:Dat 7 .
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA
?D� l,o
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C. 27028
(7 04) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site
NAME � G� �1� `�1.2�c..�� DATE ISSUED 10e1117?
ADDRESS '� �� � z PERIdIT NO.
Explanation of charge
AMOUNT DUE �� SANITARIAN
PLEASE REDtIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEM T.