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P1622 Foster Dairy Rd
DAVIE COUNTY HEALTH DEPARTMENT s- (Septic Tank) Improvements Permit and Certificate of Completion (Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C) OWNER OR CONTRACTOR ; ; , ' ;' c DATE �' '.'. j `j? PERMIT LOCATION , v a a. t k.,/.W N? 1622 S.R. NO. SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO. HOUSE ❑' MOBILE HOME ❑ BUSINESS ❑ House Trailer 800 Gal. 400 Sq. Ft. N0. BEDROOMS �-% NO. BATHROOMS i Two Bedroom House 800 Gal. 600 Sq. Ft. GARBAGE DISPOSAL UNIT YES ❑ NO ©-- Three Bedroom House 900 Gal. 900 Sq. Ft. AUTO. DISHWASHER YES Q] NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft. AUTO. W4SH. MACHINE YES [0 NO ❑ SITE SUITABLE YES C] NO SIZE OF TANK Ar gal. NITRIFICATION FIELD N L i ''/ s q. ft. DEPTH OF STONE IN LINES: WATER SUPPLY: Individual ❑ Public ❑ IMPROVEMENTS PERMIT BY-- INSTALLED BYia CERTIFICATE OF COMPLETION By Dat e�l� (8/16/73) *Construction must comply with all ther applicable State and local regulations LOT AREA ` r .� DAVIE COUNTY HEALTH DEPARTMENT` � P. 0. BOX 57 b�,,/,W77 HOCKSVILLE, N. C. 27028 (704) 634-5985 p Statement for Septic Tank Improvement Permits `. and/or Site Evaluations NAME/, DATE ISSUED � % ADDRESS ;1 �,.,�, 3 PERMIT N0. Explanation of charge lT� AMOUNT DUE '� SANITARIAN PLEASE RE14IT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.