P1724 Hwy 64E + ' ' DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130-Article 13C)
OWNER OR CONTRACTOR N it DATE l/ ,{ PERMIT
LOCATION
N° 1724
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S'.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE ;HOME • ' BUSINESS ❑
i House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS ` NO. `BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO 0'~- Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES ❑ NO [3--- Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES I7 NO ❑
SITE SUITABLE AYES NO ❑ C�j(��` �i'�[ ✓ Z� / �
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft. /
DEPTH OF STONE IN LINES: .�'
WATER SUPPLY: Individual ❑ ,✓Public ❑
IMPROVEMENTS PERMIT BY INSTALLED BYOf
., �
CERTIFICATE OF COMPLETION I
By ce jj Pq k I-• Date a7 /
(8/16/73) *Construction must comply with a bother applicable State and local regulations
LOT AREA
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DA I CO T HEALTH DEPARTMENT
P 0.B O X__5 7
MOCKSVILLE, N. C . 27028 `
t" (704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAPE `} %��
NAME— - DATE ISSUED �3 7
ADDRESS PERMIT NO .
Explanation of charge C /hA-
AMOUNT DUE SANITARIAN
PLEASE REMIT THE . ABOVE AMOUNT ON RECEIPT OF THIS STAT 4ENT.