4467 Hwy 801SDAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
,(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 130)
OWNER OR CONTRACTOR_C, /',�fi',i h' t" s'ie7j at--, 77 " DATE PERMIT
LOCAT" 19 2 0 '
ION
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE Er MOBILE HOME ❑ BUSINESS ❑
NO. BEDROOMS - NO. BATHROOMS _
GARBAGE DISPOSAL UNIT YES Q NO ❑
AUTO. DISHWASHER ` YES. NO
AUTO. WASH. MACHINE YES LT NO ❑
SITE SUITABLE .YES ❑ NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD sq.`.ft.
DEPTH OF STONE IN LINES: ,_,,.�+
WATER SUPPLY: Individual lam" Puhlic ❑
IMPROVEMENTS PERMIT BY
House Trailer
Two Bedroom House
Three Bedroom House
Four Bedroom House
i
INSTALLED BY
800 Gal. 400 Sq. Ft.
800 Gal. .600. Sq. Ft.
900 Gal. 900 Sq. Ft.
1000 Gal. 1200 Sq. Ft.
Ile
CERTIFICATE OF COMPLETION B}4 /,f/f1AT��ff Date -
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA f.�lf f I[�r�ic.L`-'
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DAVIE COUNTY HEALTH,DEPARTMENT
•. P 10. BOX 57,
MOCKSVILLE, N. C.-27028
1 (704) 634-5985
Statement for Septic Tank Improvement Per is
and/or Site Evaluations
N A 149eC--Wk, lQ DATE ISSUE
ADDRES I R Zoy PER1-4IT NO .I
Explanation of charge%
f,
V V
AMOUNT D L SANITARIA
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
DAVIE COUNTY HEALTH DEPARTMENT
4 IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name Date I; x
Location �
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business _— Speculation
No. Bedrooms No. Baths _ I No. in Family
Garbage Disposal YES ❑ NO 0, Specifications for System: i t
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES ❑ NO ❑ --I
Type Water Supply 1' _
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by
*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:
I
System Installed by
Certificate of Completion `� f !'. Date ; 'f
"The signing of this certificate shall indicate that the system described 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.
i
r
Improvements permit by
*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:
I
System Installed by
Certificate of Completion `� f !'. Date ; 'f
"The signing of this certificate shall indicate that the system described 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.