P1628 Rainbow Rd-� DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR f �v� .'�--
;.._,�.�� `'.-=r�,,�., v-� : .DATE /</e-177 PERMIT
LOCATION f` . , (, ;' r NO 1628
S.R.--NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME ❑ BUSINESS Cl
NO. BEDROOMS `2� NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO 0 --
AUTO. DISHWASHER YES ❑ NO ❑
AUTO. WASH. MACHINE YES ❑,. NO ❑
SITE SUITABLE YES ❑ NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES: 1`
E- 14 L
WATER SUPPLY: v'Individual_, ❑ Public ❑
IMPROVEMENTS PERMIT BY
CERTIFICATE OF COMPLETION B
(8/16/73) *Construction mu
LOT AREA
House Trailer 800 Gal. 400 Sq. Ft.
Two Bedroom House _800 Gal. 600 Sq. Ft.
Three Bedroom House 900 Gal. 900 Sq. Ft.
Four Bedroom House 1000 Gal. 1200 Sq. Ft.
INSTALLED BY
Date
11 other applicable State and loc / ons
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DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
HOCKSVILLE, N. C. 27028 l016,J77
(704) 634-5985 /
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME vyti ti.. DATE ISSUED 16
16177
ADDRESS ��- � � `o� �7 PERMIT NO.
A l'. ado S
Explanation of charge
r'<i2i
AMOUNT DUE�s, SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.