341 Kennen Krest Lot 5 For Office Use On!y
HEALTH DEPARTMENT RELEASE
RCDP File Number 195956-1
Dave County Health Department
210 Hospital Street County ID Number-
P.O. 130rx
umber:P.O. Box 848, Evaluated For: HDRM/WC'
Mocksville NC- 27028'
Phone: 336-753-6780 Fax:336-753-1680 PERMITVAUD 0 8 ! 1 8 / a 0 a 0
UNTIL
Applicant: James Aaron Sink r
erty Owner: Jason and Ginger Moore
Address: 3524 Wyo Road ress: 341 Kennon Krest
City: Yadkinville y: Mocksville
Statef ip: NC 27055 State0p: NC 27028
Phone#: (336)244-6123 Phone#:
Road f!:Mocksville n Krest NC 27028 Property Lo eatP �sn hinformationrr Q Lot
Address Subdivision: Phase:
SINGLE FAMILY Township:
*Structure: Directions
#of Bedrooms: 3 #of People: Hwy 158 east left on Farmington/Rd Right on Mallard-Got to stop sign
tum right on Kennen Krest got to end 341 is straight ahead.
*Water Supply: NIA
Basement: n Yes D No Type of Business:
Total sq.Footage: No.Of Employees:
*Proposed Improvement:
Family Room
*Releaso 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 far any period of time.
Applicant/Legal Reps.Signature Required? Oyes ONo
ApplicantlLegal Reps.Signature: *Date:
* 2140-Nations,Robert
tissued By: Date of Issue: 0 8 1 7 2 0 1 5
Authorized State Ager —�,
**Site Plan/Drawing attached.**
;' @ Hand Drawing Olmport Drawing
HEALTH DEPARTMENT RELEASE
,aha Davie County Health Department CDP File Number: - - 1
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 8 / 1 7 I a 0 1-5
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Scale: Block
Drawing Type: Health Department Release tv/A
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Page 2 of 2
1
Davie County Health Department
�.18 fig' Environmental Health Section _rte
14 GENET P.O. sox 84s -PAID
210 Hospital Street Date:
/7
✓��'�6 l� Courser# : 09-40-06 Received b:,,
U Mocksville, NC 27028
Phone:(336)-753-6780 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection 41IM11"
a -
Name: '' a7. cs pan., S;r1; Phone Number (Home)
Mailing Address: 36ay G.1yo �. (3y) 2qq- 61a3 (Work)
Email Address:
Detailed Directions To Site: rac,_;,,mk«. Qd Frne-+ 1'Iwv 15fS - R;4. on Me,►" - 60 k-o
(,'o'Tco E7,,.d - 341 L/uYwn ICc�s� :s S�co:m,�� A po)
Property Address: _,Y41 �- 11� a70a8
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: d h /0 fV" Type Of Facility: u S�
Date System Installed(Month/Date/Year): /q-77 Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes No If Yes,For How Long?
Any Known Problems? Yes No If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:G
Type Of Facility: f d X Z Z J4941�(I 0 IM Number.Of Bedrooms: Number of People
Pool Size: age Size: Other:
9equested By: �-- Date Requested:_/3b�aDIS
(S' nature)
Approved Disapproved For Environmental Health Office Use Only
Comments: �� -/J J b 4 G '�(Or Q•y O�� ' !d rt CJ
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: Ca Ch Money Order # Amount:$ • 0 Date: d
Paid By: Received By:
Account#: Invoice#:
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Printed:Jul 30, 2015
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