1723 Jericho Church Rd (2) DAVIE COUNTY HEALTH DEPARTMENT M
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130-Article 13C)
OWNER OR CONTRACTOR DATE 4 7 I PERMIT
LOCATION n t. , r; }; i,�lt.� i1r t. a}» t'I. r. C:.. !t_L. • 1580
L+ufi S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE qg MOBILE HOME tj BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS ' NO. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES CO NO Q Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES C3 NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES NO ❑
SITE SUITABLE YES ❑ NO ❑ I
SIZE OF TANK 76-41 gal.
NITRIFICATION FIELD sq. ft. � ��
DEPTH OF STONE IN LINES: trs�X.3°X/cs'
WATER SUPPLY: Individual ❑ Public ( "
IMPROVEMENTS PERMIT BY )C k INSTALLED BY /:.%I
CERTIFICATE OF COMPLETIONBy ;J:',' ,, � t?�, ►; f,,l j— Date I J '
(8/16/73) *Construction must comply with al other applicable State and local 'regiul tions
LOT AREA
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DAVIE COUNTY HEALTH DEPARTMENT I�
P . 0. BOX 57 10'5
MOCKSVILLE, N. C . 27028
(7 04) 634-5985 J
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAMEih�.,l ? ,_�, DATE ISSUED
ADDRESS �c: �. , ryi�f PERMIT NO .
Explanation of charge
AMOUNT DU6--<15�),
PLEASE REMIT THE ABO �
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