433 N Pino Rd 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 Q/LL j M C C L(-4 NN.G N DATE 16 7e PERMIT
ATO
LOCATION P/No - /0" aQ r . �` .,/ —Gr/ '-v n�f o, -� 1\ • 1'748
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME BUSINESS ❑
/ House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS ' NO. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO 0'F Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES [7 NO ❑
SITE SUITABLE YES ❑ NO ❑ ('o O
SIZE OF TANK gal. (J
NITRIFICATION FIELD sq. ft. X 'f / p
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY i INSTALLED BYE =tJ- �
77 71
CERTIFICATE OF COMPLETION By 2 �( Date (-L-"7/
(8/16/73) *Construction must comply with all Ather applicable State and local reg lations
LOT AREA
1
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DAVIE COUNTY HEALTH DEPARTMENT
P . 0. SOX 57
MOCKSVILLE , N. C . 27028
(704) 634- 5985 _,✓�
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME /�-1�c9 C�Q��� DATE ISSUED
ADDRESS PERMIT NO.
Al
.Explanation of charge
AMOUNT DUE ,''�- SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.