P1947 Liberty Church Rd DAVIE COUNTY HEALTH DEPARTMENT
-✓ (Septic Tank) Improvements Permit and Certificate of Completion
(Gr-ound Absorpt4on Sewage Disposal System- G.S. Chapter 130- rt cle 13C)
OWNER OR CONTRACTOR ♦, !( >}.. .!L.f. . (;(.lL,t�, (,s DATE PERMIT
19 4
LOCATION r ?- �i3•i'l. 1ts ; ..(, : { � ((.1, ,. 4 N° '7
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO,
HOUSE ❑ MOBILE HOME BUSINESS`❑
House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS NO. BATHROOMS Two Bedroom House 800 Gal., 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO ❑ Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES ❑ NO ❑
SITE SUITABLE YES ❑ NO ❑ ,+ M!" �
SIZE OF TANK gal. aot
NITRIFICATION FIELD sq. ft. te
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ ` 'Public'
IMPROVEMENTS- PERMIT, BY l ,.� INSTALLED BY . .4 �
CERTIFICATE OF COMPLETION By p� E}1(l. b Date
(8/16/73) *Construction must comply with all they applicable State and local regulations
LOT AREA
T
DAVIE COUNTY HEALTH DEPARTMENT _ y
w P . 0. BOX 57
MOCKSVILLE, N. C . 27028 f✓Y`� �'�- a�l
704 -P 634-5985 � D�
Statement for Septic Tank Improvement Permits 112'r
and/or Site Evaluations
NAVE DATE ISSUED
rX1
ADDRESS'' � PERMIT N0701.
i
Explanation of charge
AMOUNT DUE SANITARIAN
PLEASE REMIT THE ABOVE A14OUNT ON RECEIPT OF THIS STATEMENT.