P1816 CooleemeeDAVIE 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 /-'e7 .% rs, i i r e ' DATE PERMIT
LOCATION
4N # S. R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE [Er MOBILE HOME BUSINESS ❑
1816
SIZE OF TANK gal. (i
NITRIFICATION FIELD sq. ft. r ./
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑ �: .,,_��_
IMPROVEMENTS PERMIT BY � ,ter-<y� `,tt%;r.,� INSTALLED BY _: ,^,�}�T�
CERTIFICATE OF COMPLETION
By -
(8/16/73)
Y (8/16/73) *Construction must comply with all ther applicable State and local regula ions
LOT AREA
f
611
:5 }
f;
t
t
House Trailer
800
Gal. 400 Sq.
Ft.
N0. BEDROOMS
N0.
BATHROOMS
Two Bedroom House
800
Gal. 600 Sq.
Ft.
GARBAGE DISPOSAL UNIT
YES
❑
NO
0''�
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
P
NO
❑
SITE SUITABLE
YES ❑
NO
❑
/
�f
SIZE OF TANK gal. (i
NITRIFICATION FIELD sq. ft. r ./
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑ �: .,,_��_
IMPROVEMENTS PERMIT BY � ,ter-<y� `,tt%;r.,� INSTALLED BY _: ,^,�}�T�
CERTIFICATE OF COMPLETION
By -
(8/16/73)
Y (8/16/73) *Construction must comply with all ther applicable State and local regula ions
LOT AREA
f
611
:5 }
f;
t
DAVIE COUNTY HEALTH DEPARTMENT,
P. 0. BOX 57
MOCKSVILLE, N. C. 27028L-
(704) 634-5985 %
Statement for Septic Tank Improvement Permits
f�� 1
and/or Site Evaluations
NAPI:E 'D DATE ISSUED T
ADDRESS , <��'-�-�'- PERMIT NO.
Explanation of charge
` d--Id-,,,-AMOUNT DUE/ •� - SANITARIAN l
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.