141 Wills Road Lot 5DAVIE COUNTY HEALTH DEPARTMENT
�- ' • (Septic Tank) Improvements Permit and Certificate of Completion
'? (Ground Absor tion wagetDisposal System - G.S. Chapter 130 -Article
13C)
OWNER OR CONTRACTOR rust- , i4U.+.v DATE 7- IY' ��
PERMIT
�
LOCATION '' O( �C(.lr��., marts-
1��
1556
` S.R.
NO.
t
SUBDIVISION NAME LOT NO. SECTION OR
BLOCK NO.
HOUSE J4 MOBILE HOME t3 BUSINESS ❑
3
House Trailer 800
Gal. 400
Sq.
Ft.
N0. BEDROOMS N0. BATHROOMS .Z
Two Bedroom House 800
Gala 600
Sq.
Ft.
GARBAGE DISPOSAL UNIT YES 2' NO ❑
Three Bedroom House 900
Gal. 900
Sq.
Ft.
AUTO. DISHWASHER YES Er NO ❑
Four Bedroom House 1000
Gal. 1200
Sq.
Ft.
AUTO. WASH. MACHINE YES B' NO ❑
SITE SUITABLE YES (3' NO ❑
\
SIZE OF TANK /0,26" . gal.
NITRIFICATION FIELD sq. ft.'
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public
IMPROVEMENTS PERMIT BY
INSTALLED BY
I
I
By vv�
(8/16/73) *Construction must comply with al
LOT AREA
Date �- 3 7
other applicable state and local regul'stions
ua..A- �� t. �cJ • W`
lJ 74•Alrt� a
IL
DAVIE COUNTY HEALTH DEPARTIdENT
P. 0. BOX 57
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME?(r& �,}�. DATE ISSUED
ADDRESS 6,Rcj �hlCt�p �A.�i.�� PERMIT NO. 15-13-&
Explanation of charge
r
AMOUNT DUE/J !/D SANITARIAN y9C l� KL
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
U DAVIE COUNTY HEALTH DEPARTMENT
• • ° ENVIRONMENTAL HEALTH SECTION
Environmental Health Survey For Sewage Treatment and Disposal Systems
Subdivision Name
�f�fii4�lr/�nri Lot # Block or Section
Date System Installed 9�1%�/' % Name of Installer 1, 1.02"-
Number of Previous Owners /
Name of Present Owner MICHAEL C . CHAPPGC" Number of People 5 -
Add ress
"
Address /28 OIA7-75 PLACi5
Apv�,�ceN•C. 2'700
Phone No. 'cl9S 5-430
System Originally Designed For
No. Bedrooms
No. Bathrooms
Dishwasher .,14� i'Z
Disposal ;Th
Washing Machine ,/
System Now Serving
No. Bedrooms 3
No. Bathrooms 3
Dishwasher ✓
Disposal N0
Washing Machine N
Number Times Septic Tank Been Pumped Average Monthly Water Usage
Present Condition of System L- 600
Any Known Repairs to System, If So When and By Whom? Ala Al g --
Comments: Comments:
Environmental Health Official
Date