366 Bingham & Parks Rd For Office Use Only
HEALTH DEPARTMENT RELEASE
*CDP File Number 197668-1
a� o Davie County Health Department
210 Hospital Street County ID Number.
P.O. Box 848 HDR/WWC
Evaluated For:
Mocksville NC 27028
Phone: 336-753-6780 Fax:336-753-1680 PERMIT VAUD 1 0 / a 1 / a 0 a 0
UNTIL:
Applicant: Keith and Kim Dula rAd
roperty Owner: Keith and Kim Dula
Address: 366 Bingham& Parks Rd dress: 366 Bingham& Parks Rd
City: Advance City: Advance
State0p: NC 27006 State0p: NC 27006
Phone#: Phone#:
(336)940-4346 (336)9404346
Property Location& Site Information
Fingham&Parks Road Subdivision: Phase: Lot
nce, NC 27006NGLE FAMILYTownship:
Directions
9 of Bedrooms: #of People: Hwy 158 toward Advance,Bingham&Parks on right
'Water Supply: N/A
Type of Business:
Basement: F]Yes o No
Total sq. Footage: No.Of Employees:
'Proposed Improvement:
Pool
'Retease Conditions ;
Maintain 15 foot setback to any portion of the septic system I
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: 2140-Nations,Robert *Date of Issue: 1 0 / a 0 / a 0 1 5
Authorized State Agent: k!<Z_Wd99E:!�
**Site Plan/Drawing attached.**
' -@Hand Drawing Olmport Drawing
HEALTH DEPARTMENT RELEASE
,�sWf4 Davie County Health Department CDP File Number: 187689. 1
210 Hospital Street
County File Number:
P.O.sox 848
Mocksville NC 2 028 Date: 10 / a 0 / a_0 1 s
Qlnch
Scale: OBlook
awing Type: Health Department Release ()N/A
�'lov� r
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Page 2 of 2
iRECEIVED
OCT 092015
Dax ie Counter Heap?? Department _ EALTH
o g j �►p,I�` uvironmentA Health Secdoli E
11-or'. P.O.Box 848 '�
O P" 210 liospivd Street
O U , Courier#; :0940.01;
lglocksVIlle, NC 27028
Phone.(3:36)-7.B-6780 Fix:(.1:16)-753.1 W)
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: �� Phone Number � 9 40- (Home)
Mailing Address:_11(±(� `h_ 1 ! ' i (Work)
Ar c tin Email Address: (�C �rcre O"�T�t ;�C•<a .
�--� k.j.dw1j.. � �v►ht�-Gow.
Detailed Directions To Site:_
Property Address: `3Ct+cr j\=..1 ratiti5 Yc�T1�c��ktc�re j "
Please Fill In"Che Following Information About TING Facility:
Name System Installed Under. Q Type Of Facility:
Date System Installed(MonthfDateh'ear): Number Of Bedrooms. Number Of People:__
Is The Facility Currently Vacan:? YesN If Yes,For How Long?
Any Known Problems? Ya If Yes,Explain:
Please Fill In The Following Information About The NEWFacility:
Type Of Facility: r—,\ Number Of Bedrooms: Number of People_
Pool Size:�Q3') Garage Size: Other:
rtegttetecl By• 1,,-,��s�''�r.a-�",..•.._. Da1c Requested:
For Enviromnental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist Date:
*'The sitting 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 Antount:S 0 Date: 70
Paid By: Received By:
Account#: Immice#:
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