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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.** ---- ------ !.-- Cr! 6' 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 5(