118 Alder Ln (3) DAVIE COUNTY HEALTH DEPARTMENT
)MPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name ! : . i} ', ! z " '• ', Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family -
Garbage Disposal YES ❑ NO ❑
Specifications for System:,
Auto Dish Washer YES E3 NO p ' '
Auto Wash Machine YES ❑ NO -F-,J--
Type
p~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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Lprovements 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.
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Final Installation Diagram: System Installed by t ~
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Certificate of Completion � Date
*The signing of this certificate shall indicate that the system describeJ 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.
M
DAVIE COMIM. HEALTH DEPARTDM14T
PERCOLATION TEST RESULTS
DATE /D—
LOCATIOid
PIUDINGS: HOLE 110. MME-LITS
4
5
6 ! '`
By:
LOT DIAGRAM
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! DAVIE COMITY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P. O. BOX 57
: MOCKSVILLE, N.C. 27028
(704) 634-5985
Statement for Septic Tank Improvements Permits and/or Site Evaluations
NAME9e o e L 't',.;y.0 ��. S e.t WLt hc��- DATE /c3 7 J
ADDRESS . PEPMIT 140. 254-Y
COL�AX
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EXPLANATION OF CHARGE
AMOUIU DUE o•`A SA14ITARIAN
+i PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
! *NOTICE: Evaluation(s) can not be completed until payment is received..
Improvements Permit(s) can not be issued until payment is received.