2116 Liberty Church Rd (3)DAVIE COUNTY HEALTH DEPARTMENT
Oumer/Occupantt�
Address A.,4` , S . if/% Address
Address ` 6ktzPG'
�� dress
No. of lines �_ Width -� ., in. Total length A5-0 ft: No. sq. , ft.
Type of filter materialiP Total tons used
Hinimum REquirements: House Trailer Tank cap. 800 Sq. ft. line 400
Two-bedroom house 800 600
Three-bedroom house 900 900
SEPTIC TANK PERMIT Date./-/--
To:
Building Contractor R`�
Gal. 9jD0 Manufacturer's Name
No one shall install a septic tank in Davie County without a permit from the Health Offic
or his agent.
Date of Final Approval
Signed:
Sanitarian
I hereby certify that the above septic tank has been installed accordin to specification
Signed:4 /y`%vv�----
Septic TdnY Contractor
Note: Make sketch of disposal system on back of sheet and mail to Davie County Health
Center, Box 57, Mocksville, North Carolina 27028.