P2639 Farmington Rd 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
Name ' , �r Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home - Business Speculation
No. Bedrooms No. Baths 't= No. in Family
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES ❑ 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
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Certificate of CompletionDate
*The signing of this certificate shall indicate that the system describe above has been installed in compliance with
t�rz 3,� res set forth in the above regulation,but shall in NO way be taken as a guarantee that the system will function
satisfactorily7o�. any given period of time.
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DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE
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LOCATION
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FINDINGS: HOLE NO. COMIENTS
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LOT DIAGRAM
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DAVIE COUNTY HEALTH DEPARTMENT n
ENVIRONMENTAL HEALTH SECTION
+' P.O. BOX 57
MOCKSVILLE, N.C. 27028 `C n
(704) 634-5985
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STATEIREITr FOR SEPTIC TANK IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NAME LU u rc,� �o ,�.s DATE
ADDRESS �. a �� PERMIT NO.
�trnoc.Ksti.11� N,e, g tin sr
MLANATION OF CHARGE
AMOUNT DUE a 2t0b SANITARIAN_�� ,, , (1
PLEASE REMIT 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.