2108 Cana Rd 3 HEALTH DEPARTMENT RELEASE For Office Use On!y
'CDP File Number 124933-3
Davie County Health Department dao:00Q=o0-2101
210 Hospital Street County ID Number.
P.O.,Box 848 HDRNVWC
- Evaluated For.
Mocksville NO 270281
Phone:336-753-6780 Fax:336-753-1680 PERMIT VAUD 0 3 / 1 8 I a 0 a 0
UNTIL
Applicant: Robert and Kathy Ellis :::::�j Property Owner Robert and Kathy Ellis
Address: 2108 Cana Road Address: 2108 Cana Road
City: Mocksville City: Mocksville
State/Zip: NC 27028 StatefZip: NC 27028
Phone#: Phone#:
Property Location&Site Information
CAddress2�08 Cana Road Subdivision: Phase: Lot:ad# Mocksville NC 27028
SINGLE FAMILY Township:tructure: Direotlons
#of Bedrooms #of People: Hwy 601.N.tum right on,Angell Rd.then left on Cana Rd.Residence
on right."
`Water Supply: N/A
Basement: [—]Yes❑No Type of Business:
Total sq.Footage: No.Of Employees:
'Proposed Improvement:
Deck
'Release Conditions i
Maintain 5 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? 4Yes ONO
Applicant/Legal Reps.Signature: 'Date:
2140-Nations,Nations,Robert 0 3 / 1 8 / 2 0 1. 5
tissued By: Date of Issue: _ _ _ ..
Authorized State Agenttr24
: **Site Plan/Drawing attached.**
!' OHand Drawing OImportDrawing
03/11/2015 11:24 3362857466 AKR BUILDERS , PAGE 01102
Davie County Health Department
. a �► COM viromnental Health Section
P.O.Box 848
tom.. 210 Hospital Street
Courtier#:0940-06
19 i1 •
ocksville,NC 27028
Phone:(886)-753-6780
F=(886)-7531680
UST-SITE WASTEWATER CERTIFICATION
(Check One) ReplaeemeAt I2,ModeliUg Reconnection
Name: e I phone Number i (Nome)
Mailing Address: QIn / Ca ° I - 7 (Work)
Dd- 11 � f
z5( t* t l e. 1� „1 r�Q Email Address:
De ailed Directions To Site:--:T 7'O C —&:Xf T
Property.A.ddress: pr A
D G141(l�f' i l„u lam''
Please Fill IiiThe Vollowing Information About The EUSMG Facility: `q? l
System bastalled Under:
y f/ i�1 W1 7j pe Of laac' '
Name S U42-
Date System Installed(Montb/Aate/Y=):_. �'�L Number Of Bedmorms: Number Of People:
Is The Facility Currently Vacant? Ye No If Yes,For How Long?
Any Known Problems? 'Yes No If Yes,Explain:
Please Fill In The Following Wormatioa.About The NEW Facility. i
Type of Facility: 5? _ Number Of Bedrooms: � Number of People
Pool Size: Cfarage Size: Otber:
RequestedDy Date Requested: / a 0.f S
(S9gnW=)
For Environmental Health Office Use Only
Appro Disapproved
comments: C' X,;,
9-' , P---
1
• I
EnvL m ental Health Specialist Date:
*The signing bf tbis 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 fiction properly for any given period of e
Payment: Cas Check Money Order # Amou�at:$ bate:
Paid By:. Received By:
,A,ccouat#: Invoice#:
03/11/2015 11:24 3362857466 AKR BUILDERS PAGE 02/02
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s.. Printed:Mar 02, 2015
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North Carolina,its agents,consultants,contractors or employees from any and all claims or causal of action due to or arising out of the use or
Inability to use the GIS data provided by this wahsite.