565 Howardtown Rd (2) HEALTH DEPARTMENT RELEASE For Office Use only
*CDP File Number 121063.- 1
.�sro Davie County Health Department
670000000203
„ 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 VALID 0 4 / 1 a / a 0 1 3
UNTIL
Applicant: William R. Sawrey Property Owner: William R. Sawrey
Address: 565 Howardtown Rd Address: 565 Howardtown Rd
City: Mocksville City: Mocksville
State2ip: NC 27028 State0p: NC 27028
Phone#: (336)998-3614 Phone#: (336)998-3614
Property Location&Site Information
FAddress565owardtown Rd Subdivision: Phase: Lot
sville NC 27028NGLE FAMILYTownship:
Directions
#of Bedrooms: 3 #of people: 2 Hwy 158 to Howardtown Rd.on right
'Water Supply: WA
Basement: �Yes❑No Type of Business:
Total sq.Footage: No_Of Employees:
'Proposed Improvement:
Storage
Release Conditions
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 CDNO
Applicant/Legal Reps.Signature: *Date: J
*Issued By: 2244-Daywalt,Andrew *Date of Issue:. 0 4 / 1 2 2 0 1 3
Authorized State Agent:
*Site Plan/ raving attached.** Total Time:(HH:MM)
0 1 Hours 3 0 Minutes
O Hand Drawing Olmport Drawing
Davie County Health Department
qNs j�' : ., Environmental Health Section .
P.O. Box 848
210 Hospital.Street
C� ,
O U 't Courier# : 09-40-06 l 1911
Mocksville, NC 27028 Jl/
Phone:(336)-753-6780 ON-SITE WASTEWATER CERTIFICATION "" Fax:(336) 753-1680
(Check One) Replacement Remodeling Reconnection -
Name: Z/'�J'��i n yr x �/I,�/R / Phone Number `' (Home)
Mailing Address: i_4 /% ..;, .��' ... // 33 7��-CJS O
Email Address:
,..Detailed Directions To Site:
Property Address: -
Please Fill In The Following Information About The EXISTING Facility:
)
Name System Installed Under: li'✓✓>;" sr.•vQw Type Of Facility
- s
Date System,Installed(Month/Date/Year): // - ' /y y Number Of Bedrooms: Number Of People: Z
Is The Facility Currently Vacant? Yes ,,No If Yes,For How Long?
t �r
Any Known Problems? Yes No, If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
�.
Type Of Facility: _�/o/:ria,- Number Of Bedrooms: Number of People
Pool Size: Garage Size: Other:,
Requested By: Date Requested:
(Signature)
�_� '2���� For Environmental Health Office-Use Only
A pproed Disapproved
Comments: k1dr, n , 4 V 0 6,3 1 AIVU
Environmental.Health Specialist w bate: Z
*The signing of this form by the Environmental Health Staff iY 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 Cas Check Money Order # Amount:$ / ' �' Date: /
Paid By: u / Received By: G 4 ✓!' ;1 e, L'
Account#: Invoice#: