P2426 Hospital Sty DAVIE COUNTY HEALTH DEPARTMENT
,�. .,JAPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
i.; Name + l}.I 'i,t., rt r1t_lY'�vii�5 Date
1, ,
LocationOr
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Subdivision Name Lot No. Sec. or Block No.
Lot Size
No. Bedrooms
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
House Mobile Home _ Business - Speculation
_ No. Baths No. in Family 2
YES ❑ NO ❑ Specifications for System: i �,� 1�:li
YES D` NO ❑ ,, �, X. yj ,
YES p' NO C]
Cir!' 7:k
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by
*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
A
Certificate of Completion
'The signing of this certificate shall indicate that the system described
the standards set forth in the above regulation, but shall in NO way b to
satisfactorily for any given period of time. \
1)
1iDate
)ove has been installed in compliance with
(� as a guarantee that the system will function
DAVIE'COUNTY HF-ALTW'DEPART?,MNT.:,
PERCOLATION TEST RESULTS
DATE,
NA14E
LOCATION
FINDINGS: 146LE NO.
COP �TE1VT5
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DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION (�
P.O. BOX 57
MOCKSVILLE, N.C. 27028
(704) 634-5985
STATEMENT FOR SEPTIC TA14K IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NAME I b u r cr. t� � "ft- - - - DATE
ADDRESS �p r`ah��, c ea It PERMIT NO. Q4,Z t,
EXPLANATION OF CHARGES
AL14OUNT DUE C2 . YZ SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Improvements Permits) can not be issued until payment is received.