3447 Hwy 64E DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
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Name ,c t z t ,� k�. i�t I- t-' -- Date =' I 2 2-1-
Location � �� �. 1`�1= T ��1 1 jai? ! f-� � �_ �` ;=� -. �,r:i•� <,� �7. LL r_i
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 pc�=t
Specifications for System: `/00
Auto Dish Washer YES p NO p _
Auto Wash Machine YES p NO p
Type Water Supply 1 z ��- __ is �`,� 1;j
*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
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Certificate of Completion �� �`3 Date -Z�
*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
J`.' satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRON14EITTAL HEALTH SECTION
.. P.O. BOX 57 - c`
MOCKSVILLE, N.C. 27028 / Z�
(704) 634-5985
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STATyE11ENT FOR SEPTIC TANK IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NAPS N-f-1 C.T' / 1. n, Sr, -a- -, DATE I
ADDRESS ti 11, &1390 PERMIT NO. Zto Z
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EXPLANATIO14 OF CHARGE ! J(�1�/ZOI��h•�4:wgS Q �%�`�
AP40UNT 4 7o,4d SANITARIAN &�
PLEASE REMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Irrorovements Permit(s) can not be issued until payment is received.