112 R Shore Dr (2) DAVIE COUNTY HEALTH DEPARTMENT
tr_ .
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name ,� t� l�J% /,���:' Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size / /%!/' � House Mobile How — Business Speculation
No. Bedrooms -�r No. Baths _-.2 No. in Family
Garbage Disposal YES p NO p� Specifications for System:
Auto Dish Washer YES 0 NO .[] ,x
Auto Wash Machine YES ri] NO
Type Water Supply _
V
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
i-t
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:54A;l Z�2
`' i
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.
e
c
DAVIE'COUNTY HEALTH DEPARTMENT '
PERCOLATION TEST RESULTS `
DATE.
NAME
LOCATION
FINDINGS: 'HOLE N0:
4.
S.
6.
By:
0
LOT DIAGRAM
0
3
0
DAVIE COUNTY HEALTH DEPARTMENT al/ENVIRON14EITTAL HEALTH SECTION 1 C
P.O. at,�J v,;,�'J r� c
MOCKSVILLE, N.C.P1. 27028
(704) 634-5985
STATEI)XtIT FOR SEPTIC TANK IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NAME ?�. �ft / I�� DATE
ADDRESS ZZs l :A � 1�. PERMIT NO.
EXPLANATION OF CHARGE
ATHOUNT DUE/ CJS SANITARIAN %
PLEASE RMIT THE ABOVE A4OUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Improvements Permits) can not be issued until payment is received.