164 Gumberry Ln �
' DAVIE COUNTY HEALTH DEPARTMENT
' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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°Nobj:,|oaued in Compliance with G.G. of North Carolina Chapter13U-_Arho|a13c.
Permit Number
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Name Date
Location J"I
Subdivision Name Lot No. Seo. or Block No.
Lot Size House Mobile Home __ Business — Speculation
Garbage Disposal YES NO ^~— Specifications for System:
Auto Dish Washer (]
Auto Wash MaohinoYES F
Tvoa Water Supply
*This permit Void if sewage system described below i in 36 months from Uo1e of issue.
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Improvements permit bv
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*Contact o 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: 7U4'634-5QO5.
Final 20
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Certificate _ Completion-_
*The signing of this certificate shall indicate that the descriJd 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 COUI= HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE
NAIME
LOCATIOT7 �,�
MIDINGS: HOLE NO. COZ1,1ME"N S
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DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C . 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAP:'E A 4 '2 DATE ISSUED��?��` /
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ADDRESS_ �� r r f2,�_ PERMIT NO. Q,ndo
Explanation of charge fi
AMOUNT DUE-22 SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.