121 Buchin Ln (2) DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issu�rd in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name 'i— Date
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 ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES ❑ NO ❑
Type Water Supply _
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
1
1
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1
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'
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Certificate of Completion, Date
*The signing of this certificate shall indicate that the system des r bed above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way betaken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTIMNT
PERCOLATION TEST RESULTS
i
DATE
NA?4E
LOCATION
FINDINGS: HOLE NO. CO?,R4ENTS l /
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LOT DIAGRAM
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DAVIE COUNTY HEALTH DEPARTMENT
• ` ENVIRONMENTAL HEALTH SECTION
P.O. BOX 57
MOCKSVILLE, N.C. 27028
(704) 634-5985 1�1;71ellgo
STATEMENT FOR SEPTIC TANK IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NAPS Ja DATE
ADDRESS sit / PERMIT N04-v$"� (= &PO/
EXPLANATION OF CF.ARGEL 'r
AMOUNT DUES SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT OF 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.