P2717 Madison 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
71
Name ✓J ` % ��, Date 2..7
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size '' '' House v... Mobile Home _ Business Speculation
No. Bedrooms }+ No. Baths No. in Family
Garbage Disposal YES ❑ NO p /
Specifications ,for System:
Auto Dish Washer YES p NO E]' ' i' •'i'
Auto Wash Machine YES NO Q
Type Water W >
Supply _
*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 Installation Diagram: System Installed by
f. / /'L
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.
r
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRO117.4ENTAL HEALTH SECTION-..
P.O. BOX 57
MOCKSVILLE, N.C. 27028
(704) 634-5985
STATEMENT FOR SE$TIC TANK IMPROVEMENTS PE&MITS AND/OR SITE EVALUATIONS
NAPS ^., : t ate,:'/ J1//r� DATE
ADDRESS � PERMIT NO., :r
7
'EXPLANATION OF CHARGE
AMOUNT DUE SANITARIAN
-PLEASE RF_MIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.