664 Gladstone Rd DAVIE COUNTY HEALTH DEPARTMENT
r (Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption`t Sewagex1r1aW2:!j
sosal System - G.S. Chapter 130-Article 13C)
OWNER OR CONTRACTOR �()t1 h n DATEPERMIT
LOCATION Rj ` 6-6Cl 4oi,e J tM. Gam.Pl- N?. 15 8 3
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE MOBILE HOME AD BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS ---? NO. BATHROOMS Z' 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 ❑ / l/
SITE SUITABLE YES ❑ NO ❑ ��� dSIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑
r
IMPROVEMENTS PERMIT BY cx-2. ry-" INSTALLED BY
CERTIFICATE OF COMPLETION By Date
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA Faz &,/'7r1--,<
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DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
' (Ground,Absorption Sewage D{is osal System - G.S. Chapter 130-Article 13C)
OWNER OR CONTRACTOR Q oh h n `[0��U w�. DATE "a �'` /� PERMIT
LOCATION .i►It�„T.� �'LC1 f t `�(1vJts�C_ i - N° 1583
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE MOBILE HOME AD 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. ✓��V �� /� / / '
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY INSTALLED BY
CERTIFICATE OF COMPLETION Date
(8/16/73) *Construction must comply with all other applicable state and loca regulations
LOT AREA
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4 7
r 77
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DAVIE COUNTY HEALTH DEPARTMENT
P . 0. BOX 57 ? �.
MOCKSVILLE , N. C . 27028
kkI� (7 04) 634-5985
•,���1i1GiJ
L 'tement ;�r Septic Tank Improvement Permits
-_ a d/or Site Evaluations
NAME
4
ADDRESS t . 7 PERMIT NO.
k
Explanation of charge
AMOUNT DUES^//.S �� SANITARIAPJ
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.