187 Swicegood St t " o
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 ��' f� C>i� Date `� Z-'r
Location t' j:),i.,r� t� 'i_: + �'! r c c �,-' 66 oi�
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Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ '�r Business Speculation
No. Bedrooms No. Baths i No. in Family _
Garbage Disposal YES ❑ NO [7] Specificationskfor System:
Auto Dish Washer YES ❑ NO
Auto Wash Machine YES ff] NO ❑ 1
Type Water Supply Co j 0-F
`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: 704-634-5985.0,
Final Installation Diagram: System Installed bye
200 is 3 x l8
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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
satisfactorily for any given period of time.
cy
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE
4-
LOCATION
FINDINGS: HOLE NO. COM ENTS
1.
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3.
4.
S.
5.
BY:; JA5^ MA
LOT DIAGRAM
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Gc.�4Y
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DAVID; COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P.O. BOX 57
MOCKSVILLE, N.C. 27028 �-
(704) 634-5985
STATEMENT FOR SEPTIC TANK IipROVEMEws PERMITS AND/OR SITE EVALUATIONB�
NAME /L% -,.C"%�!!�,..,.i ' DATE d
ADDRESS f 'Z PEP14IT NO.
CAB e- £rf^^r F
EXPLANATIO14 OF CHARGE S/.7 `�✓fk i,�t Tt d 1J F �j/�Q S
AMOUNT '2,0. SANITARIAN
PLEASE REMIT THE ABOVE Ai�OUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE:A,Evaluation(s) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.
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