112 R Shore Dr DAVIE COUNTY HEALTH DEPARTMENT
:'•e IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'Note: Issued in Compliance with G.S. of North Carolina Chapter 130-Article 13c.
Permit Number
Name `i Date r
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms , 9 No. Baths !/ No. in Family
Garbage Disposal YES ❑ NO p--'"~�, Specifications for System:
Auto Dish Washer YES ❑ NO,.[]
Auto Wash Machine YES ❑ NO ❑ Yr�/�
Type Water Supply
G
"This permit Void if sewage-system-described-below isnot-installed-within 36-months from date of issue. 47
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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 `� ���L�
Certificate of Completion 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.
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE
NAME ,4�1,� _Z,0,'t1e e
LOCATION
FINDINGS HOLE NO. CMIENTS
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4. �v .
S.
6.
LOT DIAGRAb1
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DAVIE COUNTY HEALTH DEPARTMENT
ENVIR01IMEITTAL HEALTH SECTION
_L P.O. BOX 57 �
r`• MOCKSVILLE, N.C. 27028 �-
(704) 634-5985
STATEMENT FOR SEPTIC TANK IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NAME . .�C �^y %'i DATE
ADDRESS f -~1 � �' PERMIT NO.
F 'ter -`s--� r--p--� t- t---i
EXPLANATIOI4 OF CN.ARGE
MOUNT DUE� 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.
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