P2680 Hwy 64WDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
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Name �� Jirr'r f.r;`,- -- Date r ,r (T
Location
Subdivision Name
Lot Size
i
No. Bedrooms
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
House -
No. BathsJ:..
YES ❑ NO 0
YES ❑ NO ❑
YES ❑ NO ❑
Lot No. Sec. or Block No.
Mobile Home _ Business Speculation
No. in Family
Specifications for System:
i,,.
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit b
*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:
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System Installed by NMN k-1 -rc
0
Certificate of Completion Date L �_W_
*The signing of this certificate shall indicate that the system descriUd above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
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DATE
NAME
LOCATION
FINDINGS: HOLE NO.
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Pte' °Yl
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4.
S.
6.
LOT DIAGRAM
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COMIENTS
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DAVIE COUNTY HEALTH DEPARTMENT
ENVIRON.ME11TAL HEALTH SECTIO14
r' An P.O. BOX 57
MOCKSVILLE, N.C. 27028
(704) 634-5985
STATEMENT FOR SEPTIC TA14K IMYROVEMENTS PERMITS AND/OR SITE EVALUATIONS
EXPLANA
DATE �/% 4je
PERMIT NO. P0/ Q C/
AMOUNT DUE �� SANITARIAl�
PLEASE REMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.