968 Liberty Church Rd (2) 4 DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate.of Completion
,,- (Ground Absorption Sewage Disposal System - G.S. ,Chapter 130-Article.13C) •
rWNE OR CONTRACTOR F.I' 10A 1-- Z-1q DATE / . 7 PERMIT
.,. ZtlN� 1744
.-LOCATION * ,;,
S.R. N0,
SUBDIVISION NAME'. ? LOT'N0. SECTION OR BLOCK NO.
HOUSE JZ MOBILE HOME BUSINESS [3'
'
House Trailer 800 Gal. 400 sq. F,t.
N0:• BEDROOMS =.` NO BATHROOMS Two Bedroom. House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT, .YES ❑ NO ❑. Three Bedroom House, . , 900, .Ga1. 900 Sq. Ft.
AUTO.. DISHWASHER YES C3 NO' ❑ Four Bedroom' House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES ❑ NO ; [3
^ '
.SITE SUITABLE YES C7 NO ❑' 1L.
SIZE OF. TANK. - gal'.
NITRIFICATION FIELD sqe ftol y
• DEPTH OF STONE. IN.LINES s +p j 0410
WATER SUPPLY: :- -'Individual ❑ .Publicc ❑ {
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IMPROVEMENTS PERMIT HY .'/ .i T- INSTALLED BY
CERTIFICATE OF .COMPLETION
By Date
(8/16/73) . . *Construction•znust comply41th all other applicable State and local regulations `
LOT AREA
75 3 X a a
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DAVIE COUNTY HEALTH DEPARTMENT ,
P. 0. BOX 57
MOCKSVILLE, N. C . 27028
(704) 634-5985 Y 2
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME ., /—'�� �1�1t�=Cfy�Q� DAT E,- SSUED
ADDRESS PERMIT NO. J
r
Explanation of charge!-
4
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AMOUNT DUESANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEME T.