P1719 Sain RdDAVIE 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 DATE, PERMIT
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N° 1'719
LOCATION
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE p MOBILE HOME p BUSINESS C
NO. BEDROOMS NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO ❑
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:
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY ,�' ,',•`
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.
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INSTALLED BY �G+, mvV(,NLt
CERTIFICATE OF COMPLETION B yZ S �)k, t %� ,/,pQ 3
'V�t Date
(8/16/73) *Construction mus comply with all other applicable State and local reg lations
LOT AREA
IL
z�DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
f ' DATE ISSUED
ADDRESS PERidIT N0.
R
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Explanation
of charge
i
AN11OUNT
DUU/1
SANITARIA'
PLEASE REMIT
THE ABOVE AMOUNT 160-R�Z-PT OF
THIS STATEr4 NT.