P2617 Steve SaundersDAVIE 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 f :f- - f` –� Date
9 .1
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
YES p NO Ei
YES NO p
YES Q NO C]
Specifications for System:
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
r _ -
Improvements permit by.--'
*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.
r.
Final Installation Diagram: Svctam Installed by
�l� Caw
t
V
19
Certificate of Completion n_� f� 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.
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE
NAME
LOCATION
FINDINGS: HOLE NO.
LOT DIAGRMl
2.
3.
Z-/ �.
By:
COMMENTS
�e,1��
r.
DAVIE COUNTY HEALTH DEPARTMENT
. ENVIRONMENTAL HEALTH SECTION
. P.O. BOX 57
MOCKSVILLE, N.C. 27028
(704) 634-5985 �' ✓
STATEMENT FOR..SFPTIC TANK IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NA14E i"A(,�f> / .�f I! l�F"c DATE �� f
ADDRESS ' ; � PERMIT NO.�� O"
EXPLANATION OF CHARGE 1
, r
AMOUNT DUE SANITARIAN
PLEASE REM4IT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.