278 Fork Bixby Rd (2)DAVIE COUNTY HEALTH DEPARTMENT
:y IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name �� Date —3- 2 r- 4
Location ! 'r %. _ j
Subdivision Name Lot No. Sec. or Block No.
Lot Size House ` Mobile Home — Business __ Speculation
No. Bedrooms --4-2 No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑
Auto Dish Washer YES ❑ NO E]S e i icati ns for System: /)
C
Auto Wash Machine YES ❑ NO ❑
Type Water Supply _—
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-6' �3�•4-5985.
Final Installation Diagram: System Installed b4907-1(ajeNffrZ_1-_5 P -1-
?1 -
Certificate of Completion l Date 3 ` j F/_
#The signing of this certificate shall indicate that the system de r' ed above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be# taken as a guarantee that the system will function
satisfactorily for any given period of time.
to
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DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE
- lel
NAME
z?,o:r-
LOCATION
FINDINGS: HOLE NO. CObRIENTS
LOT DIAGRM
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4.
5.
6. `
By:
.
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
- P.O. BOK 57
a MOCKSVILLE, N.C. 27028 G�
(704) 639-5985
STATEMENT FOR SEPTIC TA14K IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NAPS e=s %✓ ' r f ,;��� ' DATE
ADDRESS PERMIT NO.
,l �ii�i j • t /'/
EXPLAIVATIOIJ OF CHARGE ... w -c.• c-�':i' , i
AMOUNT DL
SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.