P1549 Hwy 158DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR 12---z-
DATE PERMIT
LOCATIONQL, % 6 ,,, .. 15 4 9
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE [ MOBILE HOME ❑ BUSINESS
NO. BEDROOMS _ 3 NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO B—
AUTO. DISHWASHER YES ❑ NO [--
AUTO. WASH. MACHINE YES NO ❑
SITE SUITABLE YES NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY
CERTIFICATE OF COMPLETION
By_
(8/16/73) *Construction must
LOT AREA
House Trailer
Two Bedroom House
Three Bedroom House
Four Bedroom House
800
Dd
Gal.
400
Sq.
Ft.
800
Gal.
600
Sq.
Ft.
900
Gal.
900
Sq.
Ft.
1000
Gal.
1200
Sq.
Ft.
X3
INSTALLED BY Cyd »tirn. t
Date
ly wither all ot(er applicable State and local I�e6 fat�ons
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57 V
MOCKSVILLE, N. C. 27028
(704) 634-5985 /
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME (�_A�?.-^�•��,, i�%,�-� DATE ISSUED
ADDRESS i �;u,.,�� ��, �_ PERMIT NO.
Explanation of charge
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J
AMOUNT DUE SANITARIAN
SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEDENT.
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