P1754 Hwy 64W" 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 r;!_ <_ DATE `r;' PERMIT
LOCATION 1754
i� lr
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE p MOBILE HOME W BUSINESS
NO. BEDROOMS NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO ❑"
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
House Trailer
Two Bedroom House
Three Bedroom House
Four Bedroom House
800
Gal.
400
Sq.
Ft.
800
Gal.
600
Sq.
Ft.
900
Gal.
900
Sq.
Ft.
1000
Gal.
1200
Sq.
Ft.
INSTALLED BY
CERTIFICATE OF COMPLETION :- tir.� r, < r� ,�r'
BY � Date `�
(8/16/73) *Construction must comply with all other applicable State and local egulations
LOT AREA
W�
DAVIE COUNTY HEALTH DEPARTMENT II
P. 0. BOX 57
MOCKSVIILLE, N. C. 27023 _
(704) 634-5985
Statement for Septic Tank Improvement Permits{
and/or Site Evaluations _
NAMI E�,y�,Q�i DATE ISSUED 7
ADDRESS � / PERMIT NO.
)v.0 � bzg
Explanation of -charge
AMOUNT DUE SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATWIENT.