P2634 Trivettec: _" 4
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. -
Permit Number
Name ` Date
Location — -E —
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business __ Speculation
No. Bedrooms — No. Baths _ No. in Family _
Garbage Disposal YES ❑ NO ❑ Specifications for System: -
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES ❑ NO ❑
Type Water Supply __—
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by
r
,
`Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram:
System Installed by
Certificate of Completion ' Date
"The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
F
DAVIS COUNTY FiEALTIi DEPAR I -MUT
DATE
ty
LOCATION;
PERCOLATION TEST RESULTS
FINDINGS:
LOT DIAGARAP1
HOLE 110.
By:
CO: MEWS
F e4ly —
�� r
-11
S
mii 1
DAVIE COMITY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION (�
P. O. BOX 57 Q
MOCKSVILLE, N.C. 27028
(704) 634-5985
Statement for/Septic Tank Improvements Permits and/or Site Evaluations
YQAME %/1J ( DATE
Com'
ADDRESS PERPIIT 140. '
EXPLANATION OF CHARGE
At-floUiJT DUEO '04) SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEi`REIV'IT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Inprovemsnts Permit(s) can not be issued until payment is received.