P121273 Hwy 64EDAVIE COUNTY HEALTH DEPARTMENT SEPTIC TANK PEWIT Date Ja _/a - i
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)i&mer/Occupant ���.��j,� c�--L_ To:
Address Address
Buildino Contractor Address
Cal. jr�- Manufacture s Name Address,}-�
No. of lines - Width ?Ain. Total ength s9 <57D ft. No. sq. ft. 9 cj'D
Type of filter material _ �, Total tons used
minimum REquirements: House Trailer Tank cap. 800 Sq. ft. line 400
Two-bedroom house 800 600
Three-bedroom house 900 900
No one shall install a septic tank in Davie County without a permit from the Health Offic
or his agent.
� A
Date of Final Approval .�Z /--� Signed:�.
Sanitarian
I hereby-certify that the above septic tank has been installed according to specificatiol
Signed: .1
Septic Tank ContractorT'-
Note: Make sketch of disposal system on back of sheet and mail to Davie County Health
Center, Box 57, Mocksville, North Carolina 27028.