881 Rainbow 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 ' DATE i".' PERMIT
LOCATION j l�� 1898
O S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME - BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
N0. BEDROOMS NO. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO ❑' Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YESD"r NO ❑
SITE SUITABLE YES [3r- NO ❑ - r':' ::,�
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY fir' t ;' INSTALLED BY
CERTIFICATE OF COMPLETION By (,,/ (3 �(Gl1 } f�I- Date g
(8/16/73) *Construction must comply with al other applicable State and local r gulations
LOT AREA
r..
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C. 27028
(704) 634-5985 �� a
c�
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME � ' �� DATE ISSUED r�
ADDRESS .% _, j � ;r�/ f��l% PERMIT NO.
J
i
Explanation of charge
AMOUNT DUE fry` SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEM NT.