777 Jack Booe 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: Jerry E. Tullock
Address: PO Box 68
City: Mocksville
State/Zip: NC 27028
Phone #: (336) 492-3106
For Office Use Only
*CDP File Number 121698 -1
C2-000-00-038-05
County ID Number:
valuated For: HDR/WWC
PERMIT VALID 0 5 1 2 4/ 2 0 1 8
UNTIL
Property Owner: Jerry E. Tullock
Address: PO Box 68
City: Mocksville
State/Zip: NC 27028
Phone #: (336) 492-3106
_ Property Location 8. Site Information
•-AddressesJa Odd 9 Subdivision:
Road # Mocksville NC 27028
Phase: Lot
SINGLE FAMILY Township:
'Structure: Directions
# of Bedrooms: 3 # of people: 2 Hwy 601 N. Left on Jack Booe Rd. 1 1/2 miles on the left
`Water Supply: WA
Type of Business:
Basement: � Yes ❑ No
Total sq. Footage: No. Of Employees:
'Proposed Improvement:
Metal Garage
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? Oyes eNo
Applicant/Legal Reps. Signature;
*Issued By: 2244 - Daywalt, AnclN
Authorized State Agent:
*Date:0 5 2 4% 2 0 1 3
*Date of Issue:.0 5/ 2 4/ 2 0 1 3
**Site P Iaftrawing attached.** Total Time:(HH:MM)
0 1 Hours 0 0 Minutes
UHand Drawing Olmport Drawing
Davie County Health Department
1836' --Environmental fi Health. Section
T� P.O. Box 848
ev
� e:
�- (1-} ) 3 ,i 210 Hospital Street
O �`�. �no1b ; Courier # 09-40-06
tui
Mocksville, NC 27028
Phone: (336) - 753 - 6780
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
Fax: (336) - 751- 8786
Name: _ _Set 6- y 45_ l u( I O C iG Phone Number - y 9 - l 0- (Home)
Mailing Address: P • 0 o k (n? tell 336' t' -t rj IR -') I P-60 (Work)
m ki l k - .' Email
a_70L.? _
Detailed Directions To Site: lk w N L _ Got 6 r k k t o L E Q r Z a C k
Property Address:_
Please Fill In The Following Information About The EXISTING Facility:
GZ-UUD- oo-
L -C b",
a�lo�8
Name System Installed Under: G QC c.a f CL r-% r1 Type Of Facility: (X\
Date System Installed (Month/Date/Year): 1 D - ZL CO.O Number Of Bedrooms: J Number Of People:-
Is
eople:
Is The Facility Currently Vacant? Yes No If Yes, For How Long?
Any.Known Problems? Yes eIf Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: f'V\ �-0. A a_ -V I.Ci Q -_ Number Of Bedrooms: Number of People
11
Requested By: QJ am P A-, Date Requested:
( 'gnature
For Environmental Health Office Use Only
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:
Order #
1) D, Date:
Paid By: / Received By:
Account #: Invoice
S
1-t
0
L i V,
n
UMC!cC k
L.ga.- 3 to G
Celt 33�- (�'7g-r7 w -c.
I L, rI -v
Account #: 990002736
Billed To: David Gordon
Reference Name:
Proposed Facility: Residence
ATC Number: 4758
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
OPERATION PERMIT
Tax PIN/EH #: 5870-05-2862
Subdivision Info: Baltimore Heights II Lot # 7
Location/Address: Montclair Drive -27006 2(00
Property Size: 100x345
**NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed
in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems,"
but shall in NO WAY be en as a guarantee that the system will function satisfactorily for any given period of
time.
System Type: S.T. Manufacturer Tank Date / Tank Size
Pump Tank Size
System Installed By: 0 0A /V ► k 0 A E.H. Specialist:� , 0A b' Date:
^t AV
DCHD 11106 (Revised)
Account #:
Billed To:
KCI GIGua.c ��a��w•
proposed Facility:
ATC Number:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
990001367
Tax PIN/EH #:
5812-37-2689.05
Gary Brannon
Subdivision Info:
77-7
Mackie McDaniel
Location/Address:
Jack Booe Road -27028
Residence
Property Size:
see map
2558
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization. for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatm t and Disposal Systems). THIS '
AUTHORIZATION FOR WASTEWATER C0NSTIKTI0N)1S VAkW QR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature:
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given period of time. / ,, '
"W fop
'7) it
/'m t Lj j1
711 & jri'o i+PST-
10-0, 7 -
Septic System Installed By:
Environmental Health Specialist's Signature
DCHD 05/99 (Revised)
Date: 101240