938 Howell RdHEALTH DEPARTMENT RELEASE
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: David Graham
Address: 938 Howell Road
City: Mocksville
State2ip: NC 27,028
Phone M (336) 940.5104
For Office Use Only
*CDP File Number 195652-1
County ID Number.
Evaluated For. HDRNVWC
PERMIT VALID 0 8/ 1 1/ a 0 a 0
UNTIL:
/ Property Owner: David Graham
Address: 938 Howell Road
City: Mocksville
State2ip: NC 27028
Phone #: (336).940-5104
Property Location & Site Information
Address938 Howell Road Subdivision: Phase: Lot
Road # Mocksville NC 27028
SINGLE FAMILY Township:
'Structure: Directions
# of Bedrooms:. 3 # of People: Hwy 601 North left on Eaton's Church Rd. left on Howell Rd property
on right
'Water Supply: N/A
Basement: F1 Yes ❑ No Type of Business:
Total sq. Footage: No. Of Employees:
'Proposed Improvement:
Replace mobile home
Maintain a 5 foot setback to any portion of the septic system
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:
2140 - Nations, Robert
Issued By: Date of Issue: 0$ _ 1 1 x 0 1 5
Authorized State Agent:
**Site Plan/Drawing attached.**
"and Drawing Olmport Drawing
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Phone: CM - 70 - 67W
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Davie Comity Health Department
&viromuenW Health Section
RECEVP.O. Box 848
Dain
210 Hospital Street
Courier #: 09-40-06
Xlod-,sville, NC 27028
Fwa M - 753-IrM
ON-SITE WASTEWATER CERTIF=Reconnection
(Check One) Replacement Remodeling
Name: cJ1 ('ju 6y"Jj PhoneNumba l/�" Y7i% • ��iyy (Home)
Mailing Address: e Y P' VwezL (Z-� _ � ' 2'1 J (%York)
SCh/U��
Detailed Directions To Site: (001 �D✓1ZN- 5 4� �i"O✓�� CnCI{l.+rZ�- l2i
Property Address: R3;?g9r,!L VL17 my[/�sv(c,L�..✓c_ 2�
Please Fill In The Following Information About The EXISTING Facility: ,,LL
Name System Installed [tinder: L0�✓ /ylvW Type OfFacffidy: Mc913/L 7�Mb�
Date System Installed (Month/Date/Year): 7 Number Of Bedrooms: .3 Number Of People:
Is The Facility Currently Vacant? Yes No If Yes, For How Long?,
Any Known Problem Yes IFYes, Explain_
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: /11 ry Dy C4� l%o b' Number Of Bedrooms: 3 Number of People
Pool Sim Gramge Sim -�" Other:
_19 -
Requested By: Date Requested: /Z
For Environmental Health Office Use Only
Approved Disapproved
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
mited) that the on-site wastewater system will function properly for any given peri
Payment: Cash(' Check] Money Order #
Paid By. J ReceivedBv_
Account #: Invoice #:
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