P1567 Country Cove - Don PatrickDAVIE 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 1'C'11 YA'Ti-- t'. DATE ': • y% PERMIT
LOCATION .0 �ti�Y�a n-;.-�w r ,2�, C. i r L C�1 - C7 E` i a i' C`t/s r •,' r •� �5u c. lr
SUBDIVISION NAME
LOT NO.
S. R. NO.
SECTION OR BLOCK NO.
1567
HOUSE 14 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 [�'
Three Bedroom House
900
Gal.
900
Sq.
Ft.
AUTO. DISHWASHER
YES
Q' NO ❑
Four Bedroom House
1000
Gal.
1200
Sq.
Ft.
AUTO. WASH. MACHINE
YES
C NO ❑
SITE SUITABLE
YES
❑ NO ❑
SIZE OF TANK
gal.
NITRIFICATION FIELD
sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual
9?0' Public ❑
IMPROVEMENTS PERMIT BY '\ L -Z. rf1Lt,JO I INSTALLED BY
CERTIFICATE OF COMPLETION By nl0, Date
(8/16/73) *Construction must comply with all other applicable State and local regu ations
LOT AREA %ltd X /car ?,r6 7al'.711t�Vot
yn.r
sI
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57- Q''PJ
HOCKSVILLE, N. C. 27028 C"
(704) 634-5985
U
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME Icti- '�)njr,c DATE ISSUED Q-,�-77
ADDRESS (', H ��,�ta',� �PERMIT NO.
Explanation of charge)-
AMOUNT
harge}_
AMOUNT DUE SANITARIAN �
PLEASE RE14IT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.