P2651 Jason DickensDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Name - Date i
Location i r!
Permit Number
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 ❑ J� . Specifications for System:
Auto Dish Washer YES ❑ NO ❑'
Adto 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.
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Improvements permit by
`Contact a representative of the Davie County Health Department for finaun pection 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: ' f,ur System nstalled.by
Certificate of Completion (%%f/' / , Date/- zt?"
*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 / ;!?' '
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NAME 5 -
LOCATION LOCATION
FINDINGS: HOLE NO. C01-24ENT5 a„.
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By: /
LOT DIAGPM
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rf DAVIE COMITY HEALTfri DEPARTMENT +
%-, ENVIRONMENTAL HEALTH SECTION
"P. -0, , BOX --57
MOCK.SVILLE, N.C. 27028-
(704) 634-5985
Statement for Septic,Tank Improvements Permits and/or;Site Evaluations
NAME � � � " . �',r��GU � DATE
ADDRESS / / y=�-�ir' ,%�/ i% PERPdIT 140.---'l'
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EXPf&'IATION OF CHARGE /«� SLP "C*�` ; f �'+-%'�' �
AMOUNT DUE `J( L� t SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OFF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.