587 Liberty Church Rd (2)DAVIE 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
Name Date - ;� , 22
Location
- r
Subdivision Name Lot No.
Lot Size House Mobile Home Business
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO
Auto Dish Washer YES ❑ NO p --
Auto Wash Machine YES N0 i❑
Type Water Supply
Sec. or Block No
Specifications for System:
s
Speculation
*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:
"The signing of this cer
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system wiii function
satisfactorily for any given period of time.
System Installed by
1
,m '--
DAVIE COUNTY' HEALTH DEPARTMENT
P'. -O. BOX 57
7c
HOCKSVILLt, N. C. 27028
-(70*41) 634-5985
Statement for Septic Tank Improvembnt Permits
and/or Site Evaluations
NAME%J2Eit/Lc.=�DATE ISSUED 7z
ADDRESS PERMIT NO.
4:�L:;2
76
Explanation of charge
'AMOUNT DU SANITARIA
PLEASE REMIT THE ABOVE AMOUNT ON'RECEIPT OF THIS STA
MENT.