653 Bell Branch Rd (2) KEAUTH DEPARTMENT RELEASE For Office Use Only
*CDP File Number 138712-1
�A Davie County Health Department
„ 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 VALID 0 6 / 0 4 / .1 0 1 9
UNTIL
Applicant: Eric Wilson Property Owner. Eric Wilson
Address: 653 Bell Branch Road Address: 653 Bell Branch Road
City: Mocksville, City: Mocksville,
State2ip: NC 27028 State/Zip: NC 27028
Phone#: (336)463-2805Phone#: (336)463-2805
Property Location& Site Information
Address653 Bell Branch Road Subdivision: Phase: Lot
Road# Mocksville NC 27006
SINGLE FAMILY Township:
`Structure: Directions
#of Bedrooms: 3 #of People: Hwy 601 North tum left on Chinquapin Rd.go 2 miles left on Bell
Branch Rd.Will be on right
'Water Supply: NIA
Type of Business:
Basement: �Yes❑No
Total sq.Footage: No.Of Employees:
`Proposed Improvement:
Garage
'Release Conditions Oct::e.
Maintain 2 foot setback to septic system and 25 foot from the well 61
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? QYes ONo
Applicant/Legal Reps.Signature: *Date: 0 6 / 0 5 / .1 0 1 4
*Issued By: 2140-Nations,Ro *Date of Issue:. 0 6 / 0 5 / 2 0 1 4
Authorized State Agent::�r� 1�0�lfe�pk
**Site Plan/Drawing attached.**
Hand Drawing O ImportDrawing
D . .
i r
Date: .1rj 2 ��,�!`>..
RECEIVED
ReceivedDavie County Health Department Date: 5 z�
4is Environmental Health Section ;
P.O. Box 848
210 Hospital Street +/
Courier# : 09-40-06 +c�
Mocksville, NC 27028
Phone:(336)-753-6780 Fax:(33I6),-755,3,-1680
✓mi
ON-SITE WASTEWATER CERTIFICATION Cau e
(Check One) Replacement Remodeling Reconnection (g 9
Name: r r' V'' (` I s Phone Number 3 3 4 ) " b 3 2-o S (Home)
Mailing Address: b S 3 1 / n c I�-d � T (a 9 2'7 b Q i(Work)
/VC 27o 2VEmailAddress: 1.✓r'�5�� yob f c I . A ,c�
Detailed Directions To Site:l'a (uh-e-n S A4Ache .
Property Address: (Q�3 l�� /�ttj
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: Type Of Facility: iZe S
Date System Installed(Month/Date/Year): 1 Number Of Bedrooms: 3 Number Of People:_
Is The Facility Currently Vacant? Yes to If Yes,For How Long?
Any Known Problems? Yes If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: bg r Q a -t Number Of Bedrooms: Number of People
Pool Size: Garage Size: aP`x Z`P Other:
Requested By: Date Requested: 2Q"
(Signature)
For Environmental Health Office Use Only
("ro Disapproved
Comments: '
Environmental Health Specialist c% Date: G
*Thesigning 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.
Payment: Cash Check Money Order # Amount:$ /UD •00 Date:
Paid By: rj L 0.);ks6 i1 Received By: 130
Account#: 13 —Invoice Invoice#:
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'.ARCEL NUMBER B200000031
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LEGEND ~----
EIP EXISTING IRON PIN
IPS _ IRON PIN SET
PT '`POINT
. .. DAVIE COUN'T'Y HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
-_---__`-____Mocksville,NC 27028 ---
(336)751-8760
Account #: 990004079 Tax PIN/EH#: 5814-30-4694
Billed To: Eric Wilson Subdivision Info: 3
Reference Name: Location/Address: -4*Bell Branch Road-27028
Proposed Facility Residence Property Size: See Map
ATC Number: 4494
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 14 of
—G.S.Clhapter130A;Wastewater Systems,-Section:1900 Sewage Treatment-and Disposal-Systems).-THIS -- -
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date:Date: / Oe
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improv ent/Operation Permit
has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900;�je ' e Treatment and
Ito
Disposal Systems,"but shall in NO WAY be taken as a guarantee that the system will on satisfactorily for any
given period of time.
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Septic System Installed By: 1
Environmental Health Specialist's Signature: Dat •
DCHD 05/99(Revised)