P1962 Underpass Rd� r
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 ( r ', / Y- DATE PERMIT
LOCATION ,rz ✓ ,c>,•;,r',ry" -r ,tee/ N° 1962
oe S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE Z'""- MOBILE HOME E3 BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
N0. BEDROOMS N0. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO ❑ Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES q NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES NO ❑
SITE SUITABLE YES ❑ NO ❑ % T
SIZE OF TANK gal.
'✓ Com'
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
!`Gy
WATER SUPPLY: Individual ❑ Public
IMPROVEMENTS PERMIT BYr' INSTALLED BY
CERTIFICATE OF COMPLETION,.-�f«<,*
BY .",jf_ . Date
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA
'r
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
HOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME // `.Q/ -Z DATE ISSUED
ADDRESS PERTIIT N0.L�
Explanation of charge ! • ��`.�2. �
AMOUNT DUE /s'ev SANITARIAN -
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.