224 Keepa WayHEALTH DEPARTMENT RELEASE
dsr �6 Davie County Health Department
210 Hospital Street
_ . P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Alan Miller
Address: 550 Beauchamp Road
City: Advance
StatefZip: NC 27006
Phone #: (336) 978-8132
For Office Use Only
*CDP File Number 138809-1
County ID Number.
valuated For. HDR/WWC
PERMIT VAUD 0 6/ 0 5/ a 0 1 9
UNTIL
Property Owner. Edward and Yulonda Hill
Address:
City:
StatefZip:
Phone #:
r Property Location & Site Information
Address224 Keepa Way Subdivision: Phase: Lot
Road # Advance NC 27006
SINGLE FAMILY Township:
*Structure: Directions
# of Bedrooms: 2 # of People: 1-40 east to Hwy 801, tum left going North Pass 2nd Yadkin Valley Rd.
about 1/2 Mile tum left on Keepa Way follow drive to turn left through
'Water Supply:
N/A fence/gagte.
Type of Business:
Basement: � Yes ❑ No
Total sq- Footage: No. Of Employees:
*Proposed Improvement:
Elevator and stairs
Maontain 5 foot setback to septic system and 25 from any well
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: /
*Issued By: 2140 -Nations, Robert *Date of Issue:. 0 6/ 0 5/ 2 0 1 4
Authorized State Agent:
**Site Plan/Drawing attached.**
tHand Drawing Olmport Drawing
06/0'4/2014 04:58PM 336-998-3546 MBR PAGE 01/02
_.01104/2014 16: 1 3367531680 I)CEH PAGE 02/92
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Davie County Health Department
Euvkownental Heaxth Section ATN
r P.O. Box 848
210 Hospital Street
7 Courier # : 094M6
MocbvMe, NC 27028
Mone: (&W - 7T4.. 67till ON-SrM WASTEWATER CRRTMICAx'ION F*c (SM -75 1680
(CIwok One) Repluement RemadeliEng R€coltmeC40 n ,
N%e: Af/r-. (m' , Ljwl phot -n -Mb -C (Home}
W}ing Adds wv%$ r S / Z {Rrtuie)
r� r� °ted Email Address: .�y!'7l C_b.. yrra%r�'/• ^�
Mawle$ Mr4odk a To site:
V r.a e W L-A . rf/tw• dj+t vw 0" 76" Nt!VC.. v! P
Piropaw A.ddt 2 L.. '7o P
lPlem Mill ItIbe roilavving Informadon Abaat The MUSTING Facility:
DAtq grtetn 7jot I ed (..demi O.aw/Yczr) liSxE7bei Of etfrooms:?� 'Nutab�a Of peaplc:
Is The Fadury Q 2 M+17YA=I? Yes e,% If Yes, For How
Ally ltnown Pro 7 Yes C 14Xes, > stain:
Pleslse MI Jn I M Foiiowittg•Informatlsa About The I W1~adUty:
Type Of ftcillt - VWOr n" as Number Of Eedtooms;.,,,_„iNambrr of Pevplc
Pool Site: p&MMb siao: 4t1+Ce
/RgI3cstsd EY% ate Itequestedo
i 3
For FzVh mcntai bladth Office Use Only
A.PDrevcd Dii i4j proved
Cotxuna:tg:
Envir011m6ntal tb spedalig Data:
*Tito signing M16Ls form by the EnvironmenW Hesith Staff is in no Wry itowed, nor shaald by taken as a gaets:ttco
(extends lisrdtnd) th2f the on4dta wagtewatcer oystetfi wM function far =y given period of time.
Faymcat: Cash [weak Mloneyardor 0 Dale:
Paid Bir: Received Ey:
Account 0-. 1 � �d Cl invoice 6:
,.mous i v �, vc:vvN n uu111 iauUi 1 moi viva -
000ra0ioou
DaN ie County Health Department
CEnvironmental Health Section
P.O. Box 848
210 Hospital Street
Courier # : 09-40-06
Mocksville, NC 27028
rhone: (336) - 7.5 .6780 ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
A
Fa= (336) - 753.1680
Name: �r L -1-C) Phone Number (Home)
Mailing Address
✓� cr. e, yzooG Email Address: (a Vr 4"Q' �1
7
Detailed Directic ns To Site: ,'L - YO efrT 'Ta EFwy go/ e-1, , y "a
1 ` Z ` )
tW V/d,9044 YZ i ��c. / e •vl . l% Cj ,J -
u r_e G ' o n iLw W I..•� • f i1�0'� dr i vac. f- �-✓ ^,r G n►t/ � s, +� :fi'�/
PropertyAddres : 22 LK G 700 wo- -
Please Fill In' he Following Information About
jThe MSTING Facility:
%
Name System In talled Under: � u #7 / Type Of Facility: S F Z
Date System Inst aled (Month/DateNcar): &q3 Number Of Bedrooms: 2- . Number of People: 2 -
Is
Is The Facility Q =ntly Vacant? Yes If Yes, For How Long?
Any Known Pro ems? Yes Tf Yes, Explain:
Please Fill In
Type OfFaeilit
Pool Size:
Requested By:_
Approved
Following -
Information About The NEW Facility:
Number Of Bedrooms: Number of People
Garage Size: Other:
Date Requested:
For Environmental Health Office Use Only
EnvironmentallHealth Specialist Date:
*The signing of this forst by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee
(extende or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Check Money Order # Amount:S Date:
Paid By: Received By:
Account #: Invoice #:
�i44'itti''`' N''"�""�T 4. '.4���.,._ "y,j.s„•.; � ���—*.-s.-...�•w.P'pyn.r,�...Sy��'sry?•s.'r.;�ii+'f„'sv:fy,.i4"5^�.:,r:,
DAVIE COUNTY HEALTH DEPARTMENT. _
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION U ��
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sats�taQ � wage yste� .7 Permit Number
Name �` } Date 3 �1 3 N2 72,37
Location
Subdivision Name Lot No. `' Sec. or Block No.
Lot Size House Mobile Home _- Business,"
Speculation
No. Bedrooms No. Baths No: in Family
J
Garbage Disposal YES ❑ NO Q Specifications for System:
Auto Dish Washer' YES ❑ NO ❑
Auto Wash Ma .hive YES ❑ NO ❑�� //t /� �`-' �u
Type Water Supply--- �An
h
*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.
�414
folf
Improvements permit bys"_
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A. M. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985.
Final Installation Diagram: Sy tem Installed by
N off' —
[Lop
�� �f0
p
� U
Jr
,,
of
�•Z E�r�
t Com letihn nate -93
Certificate of p
*The signing of'this certificate shall indicate that the system described 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
SV IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 1
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems�1
` � _ - 1 _ 9 3 PBfmIt,�
Date NO
Name ` _
Subdivision Name Lot No. Sec. or Block No.
V
Lot Size` House— Mobile Home Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES ❑ NO ❑ Specifcations for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Ma^hive YES ❑ NO ❑
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.
l
It,
provements permit by
�rW
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Tele �e Number 704-634-5985.
Final Installation Diagram: -
1�1
G10
Sy tem Installed by \ ;�
hNu
.d,
Certificate of Completion Date
'The signing of this certificate shall indicate that the system described 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 ENVIRONMENTAL HEALTH SECTION
\
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAMEa � \i1� `i PHONE NUMBER
ADDRESS R'c ` e -?X SUBDIVISION NAME
'�-\ Xy -'i;" H <-, -.-� LOT #
DIRECTIONS TO SITE tP N
DATE SYSTEM INSTALLED 1 9 Z] NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
Vj -;�Y' 'V.)
DATE REQUESTED - INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, g nd,,Vhjkt,I undeSstand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93