180 Buena Vista Ln (2) 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
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Name^ ti r: i, �! #y,t f Date ✓
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home =�'" Business Speculation
No. Bedrooms ��- No. Baths `�y' No. in Family
Garbage Disposal YES p NO p Specifications for System:AutoDishDish Washer YES p NO fl t-
Auto Wash Machine YES p NO
Type Water Supply
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*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 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 ' Zr�'i=it'd TJrJ
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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 betaken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE l �(
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LOCATION
FINDINGS: HOLE NO. C01•24'ENTS
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By:
LOT DIAGRM-1
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P.O. BOX 57
MOCKSVILLEr N.C. 27028
(704) 634-5985 02
STATEMENT FOR SEPTIC TA14K IDWROVEMENTS PERMITS- AND/OR SITE. EVALUATIONS
NAME ;! (i N j•1 DATE '
Vq`6
ADDRESSs PERMIT NO.
MLANATIO14 OF CHARGE ' �, 1' %•L��� '�.��✓'— 1 �: i Y'�1� ylc t..�S
AMOUNT DUE ,� SANITARIAN
PLEASE REMIT THE ABOVE A140UNT 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.