455 Frank Short Rd (2)DAVIE 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 �� f?,.�1. DateCJ_'J,r.__,�
Location -, %i i'::1.. -. ,�.4 2 —
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms No. Baths No. in Family 2
Garbage Disposal YES ❑ NO JD -
Specifications for System:
Auto Dish Washer YES ❑ NO E]
Auto Wash Machine YES ,❑ NO ❑ - `' 1 ��` X
Type Water Supply ---
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by X1122-
*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:
oe P
ep 19
e-
5A,
U� S
Syst
Certificate of Completion �\ . �o - Date
v
'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 COUNTY HEALTH DEPARTMIT
PERCOLATION TEST RESULTS
DATE
NAIIM D7 r ,��s pl.� �,,-
LOCATIOLJ ,5�
FIIIDI14GS : HOLE NO.
1
2
3
4
5
COMMENTS
50;
Cd�
6 AA
By: CO
LOT DIAG� \ �
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
HOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME QT R/; DATE ISSUED d 8
ADDRESS {�,n,--}f •%
PERMIT N0. ��5a
Explanation of charge S..Ir r uo-A .F- S • 7. 4.e-j :i
AMOUNT DUE SANITARIAN rn1,;�.�a.
PLEASE RE14IT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.