109 Apache Rd . DAVIE COUNTY HEALTH DEPARTMENT
(S -tic: JmPror�tiA?wWti:and oCxrt ate-of'C6intffAc"n"-
{�(Gre aMew6rption Sewage Disposal SystemG.S: Chapter. 130-Article 43o.
Oi�NEI��"OR CONTRACTOR °�.,.,1,; ,+ , a i 1. !' DATE' • .�4-• 011..: ;PERMIT•
LOCA ON "'" 4 ' ��' ''
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SUBDIVISION NAME ►^:;`. ,, }�`i lis
LOT A O. SECV1- OR'BLOCK NO.
HOUSE MOBILE .H 'BUSINESS ❑ ".°
�• Howe' Trailer8A .'Gal•. ~ 400 Sq. Ft.
N0. 8ED800MS �_ N0. BATHIt00!!S Two Bedroom.House 80F aj.. '600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO E3. . . Three Bedroom House _ •900 Gal: 900 Sq. Ft.
AUTO. DISHWASHER' - YES ❑.. • NO ❑ Four Bedroom -House .1,000 Gal. 1200 Sq. Ft..
AUTO. WASH. MACHINE .-.YES• V., . NO ❑
SITE SUITABLE YES- 13.. NO ❑
SIZE OF'TANK '
NITRIFICATION- FIELD sq. ft.
DEPTH OF STORE IN- LINES s `
WATER SUPPLYs Individual'. �, Public . 13
• ' ��'`"" ,
IMPROVEMENTS PERMIT BY J )N V,:10- 4 INSTALLED'o.
CERTIFICATE OFCOl�LETIpI ByW.
.. Oaf
(8/16/73) ' *Construction must' comply'aith ally other applicable_ to land 'local regulations
LOT- AREA. A a
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57 /�7
HOCKSVILLE, N. C. 27028
(704) 634-5985 '
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAMEr �� � .�.� �� DATE ISSUED
ADDRESS R4 . aZ PERMIT NO. G
-1 _r�..�.a...- 7 M(e
Explanation of charge
AMOUNT DUE SANITARIAN
PLEASE RE14IT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.