P1644 Carolyn Tuckerk
DAVIE COUNTY HEALTH DEPARTMENT
4 (Septic Tank) Improvements Permit and Certificate of Completion
,_..� (Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER.) OR CONTRACTOR = a` -. ! t Y ;:' 'j't; ; %;". is DATE i %� a°' i / PERMIT
LOCATION N?
1644
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE CI MOBILE HOME BUSINESS ❑
4,�
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 ❑ NO ❑
Four Bedroom House' 1000 Gal. 1200
Sq.
Ft.
AUTO. WASH. MACHINE YES ❑ NO ❑
- ,,
SITE SUITABLE YES Q NO ❑
„ r ; f % �. Y�`- "
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public, ❑
IMPROVEMENTS PERMIT BY y''.- - jt
INSTALLED BY L
�%
CERTIFICATE OF COMPLETION By 1 / Date
(8/16/73) *Construction must 6-ky with all o her applicable State and local regul tions
LOT AREA `--Aj /
/,.
DAVIE COUNTY, HEALTH DEPARTMENT `�j �Tt
P. O. BOX 57
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME J ,C -C DATE ISSUED 11116177
01
�'C!J
ADDRESS \,t,` G�. J� I'�" PERMIT NO.
Explanation of charge rl i,--. �,LAJ��,�
- T `SANITARIAN
AMOUNT DUE
PLEASE REMIT THE ABOVE A14OUNT ON RECEIPT OF THIS STATEM NT.