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401 Foster Dairy Rd- HEALTH DEPARTMENT RELEASE d�»s` Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: ELDEN MECHAM Address: 401 FOSTER DAIRY RD City: MOCKSVILLE State2ip: NC 27006 Phone #: (336) 998-3042 For Office Use Only *CDP File Number 121459 -1 G6-000-00-003-01 County ID Number: valuated For: HDRIMC PERMIT VALID 0 5 r/ 0 7/ 2 0 1 8 UNTIL: Property Owner: ELDEN MECHAM Address: 401 FOSTER DAIRY RD City: MOCKSVILLE State2ip: NC 27006 Phone #: (336) 998-3042 Property Location & Site Information rAddr ess40l Foster Dairy Rd Subdivision: Phase: Lot Road# MOCKSVILLE NC 27006 `Structure: SINGLE FAMILY # of Bedrooms: 'Water Supply: NIA Basement: F]Yes ❑ No 'Proposed Improvement: OUT BUILDING # of People: Township: Directions HWY 158 RIGHT ON DULIN RD. ROAD ON RIGHT Type of Business: Total sq. Footage: No. Of Employees: It is the responsibility of the owner to maintain a 5' minimum setback between the wastewater system and any part of the structure foundation, including porches, decks, and any other appurtenances. If you are unsure as to the exact location of the septic system, please have a licensed installer or inspector locate the septic system for you. The local county health department in no way implies that the proposed construction meets the required setbacks from the septic system unless otherwise noted. This release only shows that this property has an approved wastewater system that appears to have met the permitting requirements at the time it was installed. 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: *Issued By: ,_---._ ____... _ .. -... - _�___ *Date of Issue: 0 5 / 0 7 a 0 1 3 Authorized State A gent Drawing -a t-crdlhed.** TotalTlme:(HH:MM) -- - 0 a Hours 0 0 Minutes Hand Drawing Import Drawing Davie County Health Department 9 his t� Environmental Health Section _ M-. P.O. Box 848 r 210 Hospital Street� Courier # : 09-40-06 Mocksville, NC 2702E Phone: (336) - 753 - 61H, _ Fax: (336) - 751- 8786 ON-SITE W EWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: tFlo C4/ /' �t C/Z� Phone Number 3 3�' �� ^3yy� (Home) Mailing Address: Z,/ r"64r-e 14 (Work) A9 r5V'� e 4)'C. �% � Email � a Detailed Directions To Site: 1 -0s Q -CU— Property Address:lig, IRy 14W /'I(xXs o Please Fill In The Following Information Ab out The EXISTING Facility: �%ioName System Installed Under: /� � V. Type Of Facility: Date System Installed (Month/Date/Year): /"/ '7is Number Of Bedrooms: � Number Of People: Is The Facility Currently Vacant? Yes p If Yes, For How Long? Any.Known Problems? Yes No If Yes, Explain: Please Fill In The Following Information About The NEW Facility: / Type Of Facility: (.� gat /Ava Number Of Bedrooms: Number of People Requested By: Date Requested: S''3 — ,DI 3 (Signature) For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *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. Payment: Cash' Check Money Order # Amount:$ 0101 Date: Paid By:/�� eGi Q r� Received By: Account #: to NO Invoice #: 1 Davie CoVnty, NC - GoMaps Advanced Page 1 of 1 Latitude 35156' 36,42' Longitude -80131' 1617" http://maps2.roktech.net/davie_gomaps/index.html 5/3/2013 Vmoo -v '- DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION » ' 3a *NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a Sanitary Sewage Systems Permit Number Name �-_ . w-, ��y - �,. ��. � �=� L S. C�'n_ Date �� ^� - - `' N°_8082 _ Location ��` Ts \.> ocsy�\\e1 U•�_ M j h Subdivision Name Lot No. Sec. or Block No. Lot Size House — Mobile Home ____ Business Industry No. Bedrooms �% . No. Baths _ _ No. in Family �� _ Public Assembly Other Garbage Disposal YES ❑ NO 0?,' Specifications for System: P Y h Auto Dish Washer YES 3"' NO ❑ Auto Wash Ma^hine YES [Q/ NO ❑ �� ,' I �� ' Type Water Supply ,_ 'This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. t r C {r. ` Impr vements permit by *Contact a representative of the Davie County 14ealth Department for fi al inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephbne NumbQ : 704-634-5985. Final Installation Diagram System Installed by 2 w r2 n Certificate of ComptetJ Date 'The signing of this certificate shall indicate that the system detcribdd above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. ' DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE: Issued in Compliance With Article II of G.S. Chapter 130a Sanitary Sewage Systems Permit Number .tip: _ Name \ --� ,_ _- — Date _ _f. N2 8082 1 Location — is — Subdivision Name Lot No. Sec. or Block No. C .tis Lot Size ----- House — Mobile Home ---- Business -- Industry No. Bedrooms - —. No. Baths —-- No. in Family �• > — Public Assembly Other Garbage Disposal YES ❑ NO Specifications for System: r,. Auto Dish Washer YES p! NO ❑ --- Auto Wash Ma^hine YES NO ❑ i i :_, °. X l -C Type Water Supply —� ----- --- 'This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. 1� Impr vements permit by - 1 *Contact a representative of the Davie County Health Department for f\ilal inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Numb : 704-634-5985. - Final Installation Diagram: System Installed by i 1 4 v . � •�l 4�' a 2 ts! 1 Q Certificate of Completio `_--- Date 'The signing of this certificate shall indicate that the system de cribc1d above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. c�17� Y/ �, V ev '' i' ` DAVIE dbONTY ENVIRONMENTAL HEALTH SECTIO 9/el=904WC , ,� f� APPLICATION FOR IMPROVEMENT PERMIT (REPAIR rlv� � i NAME ' ✓erg %1'le- IO2YI-1 PHONE NUMBERng- ADDRESS l j 5�t- BOL1)'*_!N kcL SUBDIVISION NAME D� �Zsyi II NC_ A VIV -LOT # - DIRECTIONS TO SITE DATE SYSTEM INSTALLED /� • NAME SYSTEM INSTALLED UNDER :]& TYPE FACILITY Q M�� NUMBER BEDROOMS NUMBER PEOPLE SERVED CL' TYPE WATER SUPPLY (A I SPECIFY PROBLEM OCCURRING A)e' OGl ..5id_e DATE REQUESTED 6 �v5 / INFORMATION TAKEN BY %/ ek This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1193 A'