111 Jolley Rd (2) DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chaptgr 130-Article 13C)
OWNER OR CONTRACTOR ��`9 C l'l r: :• c j c.' „�. /�t�. DATE .� ". %�� PERM�ITT
LOCATION � � /V -- 3 f/ lr? 491
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME BUSINESS ❑
Hoose Trailer 8Q0,_ -�y�4AO. Sq.. _F.
NO. BEDROOMS � NO. BATHROOMS Two Bedroom House .8QQ� i_; .Q.(LS..q:._.F
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 �I] NO ❑
SITE SUITABLE YES NO If j x -5-
SIZE
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES: ,,..��
WATER SUPPLY: Individual ,L=i Public- ❑
IMPROVEMENTS PERMIT BY ,`� .,� - ! %r ��Mme^ INSTALLED BY _ S --V-. C.--,-
CERTIFICATE OF COMPLETION Bye Date 7- 10
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA
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