P2762 Buck Seaford RdDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name T _ Date
Location r.. G' C `�.�� : I< <: :. r C'.
Subdivision Name
Lot No
Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms I No. Baths No. in Family
Garbage Disposal YES ,❑ NO p, Specifications for System: 1:�./Lcv F:.<..c •,�`a_ I�
Auto Dish Washer YES ❑ NO Vii..
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.,
A`2 r%a.
Improvements permit by"� n^
`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: 704-634-5985.
Final Installation Diagram:
System Installed by
Certificate of Completion ��'�� Date
'The signing of this certificate shall indicate that the system described 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.
DAVIE COMTY HEALTH DEPARTMENT
s .. ENVIRONMENTAL HEALTH SECTION
P.O. BOX W f}�
MOCKSVILLE, N.C. 27028
(704) 634-5985
STATEIMUT FOR SEPTIC TANK IMPROVEM14TS PERMITS AND/OR SITE EVALUATIONS
NAME _.fie rY.. _ `j w : r � _ DATE %
ADDRESS_ _` g �� 1 uV PER241T NO. R-26,
'MLc 1tS v.1, it Y`- L
EXPiANATI014 OF CHARGE'
AMOUNT DUE =Lg&
SANITARIAN
PLEASE REZ4IT THE ABOVE AMOTNT 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.
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