206 Bear Creek Church Rd HEALTH DEPARTMENT RELEASE For office useonly
*CDP File Number .120946- 1
Health Department
Davie County
E20000002808
210 Hospital Street County ID Number:
P.O. Box 848 Evaluated For. HDR/WWC
Mocksville NC 27028
Phone:336-753-6780 Fax:336-753-1680 PERMIT vAUD 0 4 / . 1 1 1 2 0 1 8
UNTIL:
Applicant: Alean Dille Property Owner: Alean Dille
Address: 206 Bear Ck Ch Rd Address: 206 Bear Ck Ch Rd
City: Mocksville City: Mocksville
StatefZip: NC 27028 State/Zip: NC 27028
Phone It: (336)492-2239 Phone : (336)492-2239
Property Location&Site Information
CAddressL206 Bear Creek Church Road Subdivision: Phase: Lot
ad# Mocksville NC 27028
OTHERTownship:
tructure: Directions
#of Bedrooms: 0 #of People: 601 N.To Liberty Church Rd.then onto Bear Creek Ch Rd.
'Water Supply: N/A
Basement n Yes❑No Type of Business: Bam
Total sq.Footage: No.Of Employees:
`Proposed Improvement:
Horse Bam and Chicke House
'Release Conditions
This release in no way expresses or implies that the existing subsurface sewage treatment and disposal
system serving the site will continue to function for any period of time.
Applicant/Legal Reps.Signature Required? Oyes ONO
Applicant/Legal Reps.Signature,• __*Date:
*Issued By: 2244-DaywalLAndrew *Date of Issue:_ 0 4 f 1 1 2 0 1 3
Authorized State Agent: LAJ
11 V1
**Site Plan/ yawing attached.** TotalTime:(HH:MM)'
0 1 "ours 3 0 Minutes
0 Hand Drawing 0Import Drawing
Davie County Health Department
O Ps��' Environmental Health Section
,.. P.O.Box 848
210 Hospital Street
O U �y'C Courier# : 09-40-06 1911
MocPville, NC 27028
Phone:(336)-753-6780 ON-SITE WASTEWATER CERTIFICATION Fax:(336)-753-1680
(Check One) Replacement Remodeling Reconnection
Name: ' ��II�/ Phone Number Z-22 (Home)
Mailing Address: 21M to f /-1(Work)
/(//(2, ?i70-2-S Email Address:
Detailed Directions To Site:
Property Address: g o &
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: Type Of Facility: (/1�
Date System Installed(Month/DateNear): / o Number Of Bedrooms:__* Number Of People:,_
Is The Facility Currently Vacant? Yes No If Yes,For How Long?
Any Known Problems? Yes If Yes,Explain:0)
Please Fill In The Fo lowing In1krmation About The NEW cili
Type Of Facility: S % f� ZIV 3Z � 7i�ber�Of�B7eUdrooms: Number of People--"''�^
Pool Size: _ Garage Size:, .Other: �,...•�
Requested By: yDate Requested:
(ignature)
For-Environmental Health Office Use Only
=pproved) Disapproved
Comments: 1&0(11,116 /?c, i Y r, �C VG. 4)
Environmental Health SpecialistF Date: q/// C/
*The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee
(extended or limited)that the on-site wastewater system will function properly for any given period of time.
Paymen Cash Check oney Order # Amount:$ /10-06) Date:
Paid By: Received By: (/
Account#: Invoice#: b
1
I
rip i
i I I � � C e3 ,� • � � � I I.
1 I {
I tCP! II ,
;
J
NI
1 I I JJ I
� � 4
I