190 Powell Road Lot 5Y
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C. 27028
(7 04) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME +' DATE ISSUED /,7fiVl7P
ADDRESS/S ���-�+�G .��. PERMIT N 0.
Explanation of charge �" l� x``11
G ,,eo,
AMOUNT DUE d•"
PLEASE REMIT THE ABOVE A14OUNT
SANITARIAN
ON RECEIPT OF THIS STATEMENT.