775 Ralph Ratledge Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name `t� 'c%: / �. `✓ Date
Location
/ r
Subdivision Name Lot No. Sec. or Block No.
Lot Size ,House "Mobile Home - Business __ Speculation
No. Bedrooms No; Baths r`If No. in Family_ —
Garbage Disposal" YES 0 NO ❑'"
r- Specifications for System:
Auto Dish Washer YES ❑ ;'NO,`0,`
Auto Wash Machine YES ❑'NO ❑ �. ,'' f;, fir` – .
Type Water Supply
"This permit Vold if'sewage system described below is not installed within 36 months from date of issue.,,
Y
,Improvements permit by
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
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Certificate of Completion )'�` ��`�- , j
p � � Date —
*The signing of this certificate shall indicate that the system described above has�been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
. DAVIE COUNTY HEALTH DEPARTMENT
P . 0. BOX 57
HOCKSVILLE , N. C . 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or
Site Evaluations
NAME
� fl J
�'�� L� ,q �,`„f DATE ISSUED
ADDRESS_,1 pP},Y PERt!IT N0 .
Explanation of charge
AMOUNT DUE-�� oa SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
DAVIE COUNTY HEALTH DEPART'I'MiT
PERCOLATION TEST RESULTS
DATE
LOCATION rel��` � /67/
/2 /�
J4,1175�0ef Z!;7V
FIUDI:JGS: HOLE 110. Mi,iE JTS/
1004
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By:
LOT DIAGIRM
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