1324 Yadkin Valley Rd (2) ` '- % DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 13 Article 13C)
OWNER OR CONTRACTOR
PERMIT
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I
LOCATION _ . , .- 1521
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
_ HOUSE 1 MOBILE HOME EJ BUSINESS ❑
e11tI;14r11 House Trailer 800 Gala 400 Sq. Ft.
N0. BEDROOMS NO. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO B-_ Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHERYES ❑ NO QJ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES ❑ NO Q� �
SITE SUITABLE YES NO ❑ f ,� ;� x
SIZE OF TANK L gal. / ,i 7 �'' :•
NITRIFICATION FIELD / ,30 sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Inlividual Public ❑ ��
IMPROVEMENTS PERMIT BY INSTALLED BY
CERTIFICATE OF COMPLETION By Date
7 L77
(8/16/73) *Construction must comply wi hal ther applicable State and local reg lations
LOT AREA
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DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter, 130-Article 13C)
OWNER OR CONTRACTORDATE PERMIT
0
LOCATION ,�. •' " � • 1521
t S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE El MOBILE HOME Ej BUSINESS ❑
iv+f.. 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 Douse 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 ❑ ; i ;,.
SIZE OF TANK " gal.
NITRIFICATION FIELD r, sq. ft.
DEPTH OF STONE .IN LINES:
WATER SUPPLY: Individual ❑ Public ❑ +� 'x `
1;
IMPROVEMENTS PERMIT BY r . '`r../ INSTALLED BY
CERTIFICATE OF COMPLETION By Dateg/17177
(8/16/73) *Construction must comply wftT al ther applicable State and local regulations
LOT AREA
1.
' i
DAVIE COUNTY HEALTH DEPARTMENT
P . 0. BOX 57
MOCKSVILLE, N. C . 27023
(704) 634-5985 rf
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME �/ �,f;�n �t�r/l DATE ISSUED,
~ ?
ADDRESS `y�, r,w PERMIT N0:
Explanation of charge
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IN
AMOUNT DUE SANITARIAN
SANITARIAN ,
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STAT TENT.