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DAVIE 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
Name
- !%�Date
��"Location`_�,/,.^ -/I
Subdivision
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Name
Lot No
Sec. or Block No.
Lot Size -'-`��� J House Mobile Home - --''business - Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
YES ❑ NO El
YES ❑ NO [p
YES 2—NO -El
Specifications for System:
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*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 Installatioh Diagram:
System Installed by %
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Certificate of Completion �, �Date
*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.
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
/// HOCKSVILLE, N. C. 27028
1 / .(704) 634-5985
St
en t for,Septic Tank Improvement Permits
and/or Site Evaluations
NAME DATE ISSUEDAPE
ADDRESS % PERMIT NO..
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--Explanation of charge-�
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AMOUNT DUE SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS. STATEMENT.
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