P2634 Boxwood Church RdDAVIE COUNTY HEALTH DEPARTIMUT
PERCOLATION TEST RESULTS
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DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P.O. BOX 57 U U
MOCKSVILLE, N.C. 27028 tf, 2.ci
(704) 634-5985 T r
STATEMENT FOR SEPTIC TANK IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NAME—a,, M :ZA AS ,.. DATE q-61 - ZJ
ADDRESS t,ti, �� T{� PERMIT NO.
EXPLANATIO14 OF CHARGEC. L46TrAl+
XHOUNT DUEbu/h
SANITARIAN �1� ;_y�•t. _Q.
PLEASE REMIT THE ABOVE A14OUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
I=,rovements Permit(s) can not be issued until payment is received.