P1939 Hwy 158� ti DAVIE 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 DATE %tr f,- PERMIT
1939
LOCATION (.a TM. zi ;;:6 f -i ,.�G taliiel£• r�; !t%,'r:,t t�. •
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME ❑ BUSINESS Cl
NO. BEDROOMS NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO Q
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 �f Public ❑
IMPROVEMENTS PERMIT BY!%?r,
House Trailer
800
Gal.
400
Sq.
Ft.
Two Bedroom House
800
Gal.
600
Sq.
Ft.
Three Bedroom House
900
Gal.
900
Sq.
Ft.
Four Bedroom House
1000
Gal.
1200
Sq.
Ft.
F^'
INSTALLED BY��%�%
CERTIFICATE OF COMPLETION L
BY Date
(8/16/73) *Construction mus comply with all Ather applicable State and local regulations
LOT AREA
do 0 ,v` 3 x
1 4
iij�'�'.1?,'` �.1t ..,...._.."_ -/" -`iL ,� 7.,10'• i.}11�.� ��\
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations e�rrnn,,
NA@�:E /(� -/V TE
ISSUED)°�"
ADDR S �� �� , PERI:IT NO.
Explanation of charge
AMOUNT DUE SANITARIA11'. .
PLEASE REMIT THE ABOVE AHOUNT ON RECEIPT OF THIS STATt, NT.