2253 Hwy 64E • 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 CONTRACTORLi�RRLES �. GALL//� DATE _ PERMIT
LOCATION _ C/, , (y�{ E ��-� eo vt a�z��r �,d , lr 9 1536
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE [/( MOBILE HOME BUSINESS ❑
9— House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS 3 NO. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO Y 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 ❑
SITE SUITABLE YES C'S NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
/x /r
DEPTH OF STONE IN LINES:
�vtZt,
WATER SUPPLY: Individual ID PUA
14lic ❑
IMPROVEMENTS PERMIT BY INSTALLED BY
CERTIFICATE OF COMPLETION ��
BY Date
(8/16/73) *C nstruction must comply with all other applicable State and loca r`egu ations
LST AREA / � �'��
I
i
DAVIE COUNTY HEALTH DEPARTMENT
P . 0. BOX 57
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits.,
and/9q Site . Evaluations
X,0-�NAME eDATE ISSUED
ADDRESS �� PERMIT NO .
Explanation of charge f
a
AMOUNT DUE ~� SANITARIANT
PLEASE REMIT THE ABOVE AHOUNT,.ON RECEIPT OF THIS STATEME .