975 Farmington Rd (2) DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name I!`tit�. .{ :';c- ;`\► `� Date
T- 4n
Location 1: �C t ti.��`r 1,` 1 dt`l jL!.� r �r >r ,F��> t� -�, `•;i'�rr 'j "j "c i 1'i: t
L.
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 fl NO E Specifications for System:
Auto Dish Washer YES ❑ NO fl rJ
Auto Wash Machine YES p NO ❑
Type Water Supply
i
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
t
orF�
Ll
+1`
12i
Improvements permit by -'
t!
*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 by !:�'tc;
I
1
Certificate of Completion�'�/' / r Date
i6
*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.
Vii,
DAVIE COUTITY HEALTH DEPARTME
ENVIRONMENTAL HEALTH SECTIOtJ
P. 0. BOX 57
MOCRSVILLE, N.C. 27028-
(704)
7028(704) 634-5985 � C
Statement for Septic Tank Improvements Permits and/or Site Evaluations
r I-
NAME V1yto co his DATE Q, � L'•j
ADDRESS F i 143A A PEP11IT ILIO.
� 5 V1 LL �
EXPLA14ATION OF CHARGE 51?E G y ALV AT7
T'j_*R VA(T-- 11
AMOU14T D Y , SANITARIAN �"_.■��
PLEASE REMIT THE ABOVE AZIOUNT ON RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until paynent is received.
Improvements Permit(s) can not be issued until payment is received.