155 Pine Forest Ln t �
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 CONTRACTOR `.,,:/J',z.:4, t 'rt-r %. ; DATE ` ', '; ' PERMIT
LOCATION p i)f-t, .tj t .fls;te"J li
t11 C '7" . 1952
!i �� n , I .,:J. i.:..�'.. ,� �✓ �' 'S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE MOBILE HOME E3 BUSINESS ❑
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 House 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 [3 NO [3 'If�`, X1166: ,
SIZE OF TANK gal. j
NITRIFICATION FIELD sq. ft. r,
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑ 1
IMPROVEMENTS PERMIT BY 1 / .r� t .l.c INSTALLED BY�,,j�v� �F
f
CERTIFICATE OF COMPLETION BY Date5414
(8/16/73) *Construction must comply with all o her applicable State and local regulations
LOT AREA
P
71 it
DAVIE COUNTY HEALTH DEPARTMENT \
P . 0. BOX 57 C'�\
MOCKSVILLE, N. C . 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAP�:E �'� Y-v DATE ISSUED
ADDRESS PERMIT NO.
Explanation of charge
AMOUNT DUE SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STAT HENT.