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P1735 Mock
DAVIE 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 ilk," fl"�L t jl ' �' DATE f PERMIT LOCATION A :..Y' r:': r r „. t- r 1735 S -R. NO. SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO. HOUSE LE BUSINESS C7 NO. BEDROOMS NO. BATHROOMS GARBAGE DISPOSAL UNIT CES ❑ NO ©� AUTO. DISHWASHER ;,fES ❑ NO ❑ AUTO. WASH. MACHINE _YES ❑ NO ❑ SITE SUITABLE YES D NO ❑ SIZE OF TANK gall 1200 NITRIFICATION FIELD Ft. sq. ft. DEPTH OF STONE IN LINES: WATER SUPPLY: Individual ❑ Public/J ❑ IMPROVEMENTS PERMIT BYerr-- CERTIFICATE OF COMPLETION By +�¢,^'t (8/16/73) *Construction must comply with all LOT AREA 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. J INSTALLED BY Date ther applicable State and local regulations Owt�� so 1 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 Evaluat/i(ons _ NAME 7I1/lun.t,�-t.�G4LfG7 DATE ISSUED ADDRESS PERMIT NOs�'� Explanation of charge AMOUNT DUE 1J. `—' SANITARIAPJ PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATPIIfiNT. j