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2113 Hwy 801N • DAVIE COUNTY HEALTH DEPARTMENT (Septic Tank) Improvements Permit and Certificate of Completion (Ground Absorption Sewage Disposal System G.S. Chapter 130-Article 13C) j OWNER ORPERMIT -sIONTRACTOR _ /' `'.✓. � l:. �P' _"�',., _. �:� DATE �,.f`,✓,r3,wpM= LOCATION -- ��- : , r:.` " I ` ',i r yx N° 1912 S.R. NO. SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO. HOUSE ❑'` ~' MOBILE HOME BUSINESS ❑ House Trailer 800 Gal. 400 Sq. Ft. NO. BEDROOMS L .�, NO. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft. GARBAGE DISPOSAL UNIT YES ❑��NO O G- -" ' Three Bedroom House 900 Gal. 900 Sq. Ft. AUTO. DISHWASHER YES ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft. AUTO. WASH. MACHINE YES C2--NO ❑ SITE SUITABLE YES ©""'"NO ❑ G` 's�i } ' �` ,� , <. ,,� SIZE OF TANK gal. NITRIFICATION FIELD sq. ft. DEPTH OF STONE IN LINES: WATER SUPPLY: Individual Er Public ❑ IMPROVEMENTS PERMIT BY INSTALLED BY CERTIFICATE OF COMPLETION By Date (8/16/73) *Construction must comply with a other applicable State and local regulations LOT AREA 00,0 01, f'. • DAVIE COUNTY HEALTH DEPARTI,,;ENT / P . 0. BOX 57 MOCKSVILLE,--N. C . 27028 (704) 634-5985 KjN Statement for Septic Tank Improvement Permits and/orSite Evaluations ,2 — DATE ISSUED -1A/ RESSp� �ArY! b PERty1IT N0 . 17f 104/1 Explanation of charge vd AMOUNT DUE SANITAP,,IAN PLEASE REI,IIT THE ABOVE A14OUNT ON RECEIPT OF THIS STATEMENT .