1034 County Line Rd 2� 0
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*jNr16 Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. -S'•.•.�
Permit Number
Name Date 9716
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Location
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 ❑ NO 0<
Specifications for System: C�
Auto Dish Washer YES Q NO ❑ Lj �
Auto Wash Machine YES p NO ❑ �-' ' ''
Type Water Supply �, _ 1; Is,
*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
*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 A I IJ
Certificate-of'Completion '`1 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
satisfactorilyfor any given period of time.
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DAVIE COUNTY .HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE
NAME ���lTL( SPAS
LOCATION
FINDINGS: HOLE NO. COIRIENTS
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By:
LOT DIAGRM A
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DAVIE COUNTY HEALTH DEPARTMENT
_ ENVIRONMENTAL HEALTH SECTION
IL :.f '3 P.O. BOX 57
MOCKSVILLE, N.C. 27028
(704) 634-5985
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STATEMENT FOR SEPTIC TA14K IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NAME ��7 I } { S S2A'�' - DATE
ADDRESS ✓l 5 ��/��',� r i ,? 7�i< l,) ?/tl j._ PERMIT NO. l
EXPLANATIO14 OF CHARGE I t• � i , i l.,,-3�?�, f j i is � l -0 L'" -;; %'r! '. r '-�'
A11WUNT Dt Z SANITARIAN 19, ! /
PLEASE REMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not ba completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.