169 Jamestowne Dr DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION A?
"Not6: Issued in Compliance with G.S, of North Carolina`Chapter 130—Article 13c.
_ Permit Number
Name ��r }� �!. 1 f- Date 6Z�ye) ii .
_.-
Location
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Subdivision Name — Lot No. Sec. or Block No.
Lot Size -'� f' House Mobile Home _ 'Business Speculation
No. Bedrooms No. Baths r No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for;System:
Auto Dish'Washer YES ❑ NO ❑ c... '" <. '-
Auto Wash Machine YES ❑ NO -❑ r°
Type Water Supply _—
`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 by11 f t
Certificate of CompletionJ �F -Date 62-
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'"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 be taken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE 1;;; !
NAME ��
q
LOCATION
FINDINGS: HOLE NO. —COMIENTS
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By: ey
LOT DIAGRM.-I
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DAVIE COUNTY HEALTH DEPARTMENT
��.. ENVIRONM.ENTAL HEALTH SECTION
P.O. BOX 57
t MOCKSVILLE, N.C. 27028
(704) 634-5985
STATEMENT FOR SEPTIC,TANK IMPROVEME11TS PEWMITS AND/OR SITE EVALUATIONS
NAME ' j DATE
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ADD LESS: ��� � i �/,� ,��-s ir/ PERMIT NO.
415V y
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EXPLhNATIO OF CFIARGE
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Ac�UNTf D SANITARIAN
PLEASE 11M- T ,ITHE ABOVE AP40UNT OF RECEIPT OF THIS STATEMEI
*NOTICE: Evaluation(s) can not be coupleted until payment is received:
Improvements Permit(s) can not be issued until payment is receiv)M.
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