921 Williams Rd DAVIE COUNTY HEALTH DEPARTMENT ...
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sew ge Disp sal System - G.S. Chapte 1 0- rticle 13C) `{
OWNER OR CONTRACTOR '� j�, rr 04 DATE PERMIT:
LOCATIO1802
N
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.,
HOUSE ❑ MOBILE HOME BUSINESS ❑
House Trailer 800 Gal. 4,'00 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 E3--*NO ❑
SITE SUITABLE YES ET ❑ ( f a
SIZE OF TANK CSC/ gal.
NITRIFICATION FIELD sq. ft. ,+�J
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ,Public ❑
IMPROVEMENTS PERMIT BY INSTALLED BY 1 s '"
CERTIFICATE OF COMPLETION By y Date ,q
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA -,"e /
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DAVIE COUNTY HEALTH DEPARTIMENT
P. 0. BOX 57
HOCKSVILLE, N . C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME /S' � DATE ISSUED
ADDRESS PERMIT NO.
Explanation of charge
oa
AMOUNT DUE,
SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.