211 Sugar Creek Rd • -f:= 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._ _ -- Date
Location
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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 p NO p Specifications for System: `(0J,
Auto Dish Washer YESNO
Auto Wash Machine YES ate,NO :J
Type Water Supply 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 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
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Certificate of Completion �� �!I"' r1 Date
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.
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE 13 ��
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DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P. O. BOX 57 y
MO SVILLEr N.C. 27028-
(704)
7028(704) 634-5985
Statement for-'Septic Tank Improvements Permits and/or Site Evaluations
NAME 'tea i X,jC y!lR DATE
ADDRESS �. ( . 40 X r PER14IT 140.
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EXPLANATION OF CHARGE
At40Uin L) O SANITARIAN
PLEASE REMIT THE ABOVE A14OUNT ON RECEIPT OF THIS STATE.&T.
*NOTICE: Evaluation(s) can not be completed until paynent is received.
Improvements Permit(s) can not be issued until payment is received.