168 Murphy Rdr- r HEALTH DEPARTMENT RELEASE
Davie County Health Department
210 Hospital Street
t-
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Justin Draughn
Address: 641 N Main Street
City: Mocksville
State0p: NC 27028
Phone #: (336) 909-1800
PERMIT VAUD 0 8/ 0 5/ a 0 1 9
UNTIL:
Property Owner: Gary Marshall
Address: 168 Murphy Road
City: Mocksville
State/Zip: NC
Phone #:
27028
Property Location & Site Information
Address 168 Murphy Road Subdivision: Phase: Lot:
Road # Mocksville NC 27028
SINGLE FAMILY Township:
'Structure: Directions
# of Bedrooms: # of People: Hwy 601 North, past Truck Stop, Murphy Road on the left. Home on
right.
'Water Supply: N/A
Basement: r-] Yes Q No
_'Proposed Improvement:
Pole Barn
Type of Business:
Total sq. Footage: No. Of Employees:
Plumbing for this structure may be tied to home septic as long as the building is used as an accessory building for residential purposes.
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 GNo
Applicant/Legal Reps. Signature: *Date: /
*Issued By: 2140 -Nations, Robert 'Date of Issue: 0 8/ 0 5/ a 0 1 4
Authorized State Agent: --!
**Site-Plan/Drawing attached.**
---- ------ !.--
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Phone: (336) - 753 - 6780
Davie County Health Department
Environmental Health Section
RECEIVED
Date: ZC(
P.O. Box 848
210 Hospital Street
Courier #: 09-40-06
Mocksville, NC 27028
PAID
Date: 7'AI
Received by: (� {�%tA
ON-SITE WASTEWATER CERTIFICATION
0 w
Fax: (336) - 753-1680
(Check One) Replacement Remodeling Reconnection
Name: xv
,.� Phone Numbers '��°I - 1 SLh� _(Home)
Mailing Address:'—['f."�� Let4-, �n -�5VtA (Work)
VSU�L Email Address: �r,�'m ,'�� 7x A M4.1. co
Detailed Directions To Site: (Dk}r,1hn -\I- q ori. d e3 r,
Name System Installed
Information About The EXISTING Facility:
�V14dfe
,v b
�xC, L6-�- e Type Of Facility: \aim , c
Date System Installed (Month/Date/Year): � ` "i dumber Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes O If Yes, For How Long?.
Any Known Problems? Yes No If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
( f
Type Of Facility: \' 04 CC' Number Of Bedrooms: Number of People
Pool Size: Garage Size: 5o •F 40 Other:
Requested By �o �-r ,J 1�t-c �,A�r� Date Requested: 7 Z 1
(Signature)
For Environmental Health Office Use Only
Approved Disapproved `/
C nts: rt 1 S 4 J�/ �� cJ /.c d Q__ _ LOct
Environental Health pecialist'/ �.. Date:
m
Paid By:�-AAs+iK DIrLtt Cm & = Received By:
Account #: 601-7 Invoice #:
168 MURPHY ROAD
MOCK5VILLE, NORTH CAROLINA 27028
(200)
MURPHY ROAD
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