P2763 Joe Powell' DAVIE COUNTY HEALTH DEPARTMENT
f.. •' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 130,
Permit -Number
Name l'� Date
Location ,- -
Subdivision Name Lot No. Sec. or Block No.
Lot Size ;r House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO 0 Specifications for System:
Auto Dish Washer YES ❑ NO ® r
Auto Wash Machine YES E ---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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t-'
Mme.
1- f ,1,: , 1 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.
Final Installation Diagram: `.System Installed by
Certificate of Completion Date 7/XW/
*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.
DAVM COUIFTY HEALTH DEPART_IEFT
i ENVIB.01410TTAL HEALTH SECTION
SOIL/SITE EVALUATION
VAZA kjdc ease DATE
ADDRESS,
LOCATION
LOT SIZE
TOPOGRAPHY. P S
SOIL TR..TURE o
SOIL STRUCTURE,
DEPTH:
RESTRICTI'M HORIZOVS:
PERCOLATION PATE:
1.
2.
3.
Presoak
Hark & time
Drop
Time
Pate/iiir.. Inch
***CLASSIFICATIOP?: ,
Suitable Pro�yfsin ly Suitable Unsuitable
i . / i /1 e l , i
COMMITTS : ✓�ry /.�� ��ro /• /�_ , / i�fJ� �1�ri/�J�i�iyr'
SAA?ITARIAFI
SITE DIAGFA
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DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P.O. BOX 57 �A {
MOCKSVILLE, N.C. 27028
t , (704) 634-5985 ld
STATE1211T FOR SEPTIC TANK IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NAP9E �o i�j�.,/./ DATE�_�/r
ADDRESS PERMIT NO.
EXPLANATION OF CHARGE
AMOUNT DUE0"
SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Im,rovements.Permit(s) can not be issued until payment is received.
�, � : STATEMENT
DAIS COUNTY - HEALTH :DEPARTMENT
803 HOSPITAL STREET
P. O. BOX 865
MOCKSVILLE, NORTH CAROLINA 27028
.(704) 63"M
DATE
x
Joe Powell
;.a
"Oweol.�,' I
DETACH AND MAIL WITH.YOUR CHECK. , YOUR CANCELLED CHECK IS YOUR RECEIPT.
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FORM F082 Available from GRAYARC CO., INC., Brooklyn, NY 11232