193 Riverdale 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 /' 1 :�f/� /PERMIT
LOCATION 1 lr? 1640
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME Cj 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 ❑ 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 ❑ NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑ / /
IMPROVEMENTS PERMIT BY INSTALLED BY
CERTIFICATE OF COMPLETION By (,�j1_ Date
(8/16/73) *Construction must comply with all ither applicable State and local regulations
LOT AREA
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DAVIE COUNTY HEALTH DEPARTMENT
P . 0. BOX 57 f�f
MOCKSVILLE, N. C . 27028 Q
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
r _ /^
NAME 14) 1i Q DATE ISSUED- �
ADDRESS_ PERMIT NO .
t L G
Explanation of charge
AMOUNT DUE SANITARIANS n
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEME