211 Old Farm Ln DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter, 130-Article 13C)
OWNER OR CONTRACTORa.�c: (A,f DATE j;/' %`�i" PERMIT
LOCATION N9 19 91
NO.
SUBDIVISION NAME - LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME BUSINESS ❑
N0. BEDROOMS %M- N0. BATHROOMS a House Trailer �_. , 800. Gal ,__.4.QA S..q,, Ft.
:-Two Bedroom House 800 g,j.,,._.-.,..6.0,Q_S.q�:F
GARBAGE DISPOSAL UNIT YES ❑ NO ❑` MThree Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES Q NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES Q NO ❑
SITE SUITABLE YES NO ❑ %�;,� �' `'^
SIZE OF TANK gal.
NITRIFICATION FIELD sq* f t. f Ctj i. '
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public
IMPROVEMENTS PERMIT BY INSTALLED BY
CERTIFICATE OF COMPLETION Date 1'3a
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA
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DAVIE COUNTY HEALTH DEPARTMENTf�
P. 0. Box 57
MOCKSVILLE, N. C. 27028
(704) 634-5985
tit 1
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME �� l'�C/1.�1!�„� DATE ISSUED
ADDRESS, Tt� tT �� �, 1 PERMIT NO. f
Explanation of charge
AMOUNT DUE SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEa+EN .