289 Gordon Dr z. 's 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 CONTRACTOR DATE ; l PERMIT
LOCATION 19 5
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME U BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS % NO. BATHROOMS f_ Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO 0 Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES ( NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES [] NO ❑ ray �-
SITE SUITABLE YES NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD �'�) sq.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual _ ❑ Public' EJ r �
IMPROVEMENTS PERMIT BY f ,r- I.�-C ��!* f INSTALLED BY d- L Z�L
CERTIFICATE OF COMPLETION
BY -no� � 0 /-/ Date
(8/16/73) *Construction mus comply with all her applicable State and local 4egulatioris
LOT AREA "----_ -
1
Q 60
4
DAVIE COUNTY HEALTH DEPARTMENT 1�
P. 0. BOX 57 ac��
MOCKSVILLE , N. C . 27028
(704) 634-5985
b� C
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME ,. / G�r�—�-.2 DATE ISSUED e/9/7)�
ADDRESS PERMIT NO .
11, cif e"�,-?-r GC
Explanation of charge �_�_M��y-�./r✓eft-r�..�-,.�..e,. f� Ii
AMOUNT DUE /5 � SANITARIAN /
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STAT LENT .