149 Mocks Church Rd• HEALTH DEPARTMENT RELEASE
Sr
A7Fo Davie County Health Department
r `f•,t �= 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant:
Address:
City:
Charles A. Carter
149 Mocks Church Rd
Advance
State0l): NC 27006
Phone #: (336) 9984936
For Office Use Only
*CDP File Number 123149 -1
F8-000-00-036
County ID Number:
Evaluated For. HDR/WWC
PERMIT VALID 0 9/ 1 7/ 2 0 1 3
UNTIL:
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Property Owner: Charles A. Carter
Address: 149 Mocks Church Rd
City: Advance
State/Zip: NC 27006
Phone #: (336) 998-4936
Property Location & Site Information
Address 149 Mocks Church Road Subdivision:
Road# Mocksville NC 27028
*Structure:
SINGLE FAMILY
# of Bedrooms: 3
*Water Supply: NIA
Basement: R Yes ❑ No
*Proposed Improvement:
Family Room
# of People: 3
Phase: Lot
Township:
Directions
Hwy 158 East right onto Hwy 801 go to Hillcrest on right turn, to stop
sign turn right on right
Type of Business:
Total sq_ Footage: No. Of Employees:
It is the responsibility of the owner to maintain a 5 foot 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? QYes ONo
Applicant/Legal Reps. Signature. *Date:
*Issued By: 2244 - Daywalt, Andrew *Date of Issue: 0 9 % 1 7 % 2 0 1 3
Authorized State Agent:
**Site Plan/Drawing attached.** TotalTime:(HH:MM)
0 Hand Drawing OImportDrawing 0 1 Hours 0 0 Minutes
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RECEM
o ate:
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Phone: (336) - 753 - 6780
Davie County Health Department
Environmental Health Section
P.O. Box 848
210 Hospital Street
Courier # : 09-40-06
Mocksville, NC 27028
1.4ZD
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
'I
(336) - 751 - 8786
Name: C`"?a.rl � s A. Cap t(! y Phone Number ��� `� ��o (Home)
Mailing Addr ses U 9 ROC Sa(11.01 V (Work)
Tj14' �C �' LUiC. •a6� Email
Please Fill In The Following Information.About The EXISTING Facility: O
Name System Installed Under: & lr �� �� Type Of Facility:
Date System Installed (Month/Date/Year):_ `7 7% Number Of Bedrooms: Number Of People
Is The Facility Currently Vacant? Y No If Yes, For How Long?,
Any.Known Problems? es No If Yes, Explain:
Please Fill In They4llowing Information About The NEW Facility:
Type Of Facility: Number Of Bedrooms: -0— Number of People
/ICRequested By: Date Requested:
( ignature)
For Environmental Health Office Use Only
Approved Disapproved
Comments:
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
(exte d or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cas Check Money Order # Amount:$ �(��. (i Date:
Paid By: Received By:
Account #: ,4ctz Invoice #: G ✓LLe(
0, D P Al -?,a I Lo
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Printed:Sep 03, 2013
All data is provided as is without warranty or guarantee of any kind either expressed
or implied including but not limited to the implied
warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie,
North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or
inability to use the GIS data provided by this website.