240 Wyo Rd -S
;. DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
0 {. Permit Number
Name .-h C�f�l l�� ('�L 1 i) P Date / - I L �� 'r./- Ili I
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Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size �` House t,'` Mobile Home _ Business Speculation
No. Bedrooms No. Baths = No. in Family
Garbage Disposal YES ❑ NO [i] Specifications for System:
Auto Dish Washer YES ❑i NO ❑
Auto Wash Machine YES E❑ NO C] _
Type Water Supply L L,C_
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by ->
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*Contact a representative of the Davie County Health Department for final inspection Iof 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 �11 -5;
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Certificate of Completion �! Date
*The signing of this certificate shall indicate that the system descrited 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.
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DAVIE COUTITY HEALTH DEPARWlEliT
PERCOLATION TEST RESULTS
DATE
NAPS
LOCATIO. G�
FIUDINGS: HOLE NO. COMMENTS
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By:
LOT DIAGRAM
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DAVIE COMITY HEALTH DEPARTMENT �.
ENVIRONMENTAL HEALTH SECTION ,/to
P. 0. BOX 57
MOCRSVILLE, N.C. 27028-
(704)
7028(704) 634-5985
Statement for Septic Tank/ Improvemeents Permits and/or Site Evaluations
NAME AtiTb JV � -" DATE
ADDRESS �� 13-OX go � PER11IT 140.
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EXPLANATION OF CHARGE
A14OUIrl DUE- SANITARIAN, -�
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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.