P11267 Madison RdDAVIE COUNTY HEALTH DEPARTMENT SEPTIC TANK PERMIT
'_•a, of Bedrooms 3
Date 1-12--4 'Z
".`his permit is granted to
for the installation of a septic tank__
at the residence of
Address C..4r f ��
Building Contractor /4"r'a n W ---aar n 6 r 14
Address V
Septic Tank Specifications: Length Width
Depth Capacity Gal. ZO
Manufacturer's Name �a vie rs e-6 is 14x ( In,
Address �''
No,. of lines a2 width iYV in. Total Length
ft. Lo. of Sq. Ft. 9 a o
q y.pe of filter material
Total tons used
Minimum Requirements: House Trailer Tank
Cap. 800 Sq. ft. line I:00
Two-bedroom house
804
Three-bedroom house
900 900
No one shall install a septic tank in Davie County
without a permit from the Health Officer
o ris agent.
Date of final approval
Signed:it�-.�-t-cb+�__
I hereby certify that the above septic tank has been installed according to specifications.
Signed:
Septic Tank Contractor
Note: Make sketbi of disposal system on back of sheet and mail to Health Center, Mocksville,
cz -�
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