P2130 Livingston RdDAVIE 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 '%', ` `�'; :1:, ;/ ���r/, ' + '}. /a� •`• Date t� t ,� n
n .Ptiin'n' f �, s ...» f fy f ` / ✓'J.- `il ; � � i � i , `r j �' /f s';"` C�! '
Subdivision Name
Lot No.
Sec. or Block No.
Lot Size , lt✓ sir~% House Mobile Home _ Business Speculation
No. Bedrooms j No. Baths i No. in Family
Garbage Disposal YES ❑ NO [p Specifications for System:
Auto Dish Washer YES ❑ NO ❑ f� .;{: = �r/r1r,i..:a.,;.�f ,''�„t
Auto Wash Machine YES ❑ NO �]
Type Water Supply
`This permit Void if sewage system described below isnot installed'within 36 months from date of issue!/
Ll/
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: System InstalledibyL'
r�
l
/
Ot. Z
Certificate of Completion r 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�
PROCKSVILLE, N. C. 27028 ���,..•
(704) 63475985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME DATE ISSUED
ADDRESS ' P- PERMIT NO.-
Explanation of chargezm-
AMOUNT DUE SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.