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232 Odell Myers Rd (2)t t d�ST�o HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Scott Smith Address: 828 Piedmont Rd City: Lexington State2ip: NC 27292 Phone #: (336) 782-1647 r For Office Use Only *CDP File Number -175994 -1 5789-54-3471 County ID Number. Evaluated For: HDRIWWC PERMIT VALID 1 a/ 1 5/ a 0 1 9 I IAITII• Property Owner. Francis Digovanni Address: 232 Odell Myers Rd City: Advance State2ip: NC 27006 Phone #: Property Location & Site Information Address232 Odell Myers Rd Subdivision: Phase: Lot: Road# Advance NC 27006 SINGLE FAMILY Township: 'Structure: Directions # of Bedrooms: 3 # of People: Hwy 64 East tum left on Hwy 801 approx. 4 miles Odell Myers Rd on Right, Property on Right 'Water Supply: EXISTING WELL Basement: n Yes D No "Proposed Improvement: Replacing MH Type of Business: Total sq. Footage: No. Of Employees: E 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 Applicantll-egal Reps. Signature: *Date: e - *Issued By: 2140 -Nations, Robert *Date of Issue: 1 a/ 1 5/ a 0 1 4 Authorized State Agent: **Site Plan/Drawing attached.'* &Hand Drawing Olmport Drawing HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Type: Health Department Release I>w e I t CDP File Number: 175994 - 1 County File Number: 5789-54-3471 Date: 12/ 15/ a 0 1 4 Q Inch Scale: pBlock Q N/A uJa�er C'(2,14- ' Davie County Environmental Health P.O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (336) 753-1680 Application For: D Site Evaluation/Improvement Permit Xuthorization To Construct(ATC) D Both Type of Application: ❑New System DRepair to Existing System DExpansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed S c otr- Sy%,,.L Contact Person-Scotr•'Sn.Ak— Billing Address _ 4;6 Z%'\e. Moil *- b C— Home Phone City/State/ZIP 1_QXlN,%Jm s N, c- 'xj2.ctZ Business Phone 3-7 tr - -? 2 - Name Name on Permit/ATC if Different than Above Mailine Address 132- O of ..11 Mu 4. rtcvrrtci r uvrkjtumAi iN 'nate NOTE: A survey plat or site plan must accompany this application. Included: Z Site Plan UPlat(to scale) (Permit '%iXalid for 60 months with site plan, no expiration with complete plat.) Owner's Name r rm CiS Z) ;41 OJ QAJ I-- Phone Number Owner's Address�23 0 �1 M v..NS City/State/ZipAdtic,, t- AJ -C- -2792 Property Add— ;Z32 ocP.Lll M �s Rril City�UA,ur t N• r 2700L,,Lot Size Inc Tax PIN#A51 S9 S4 8 47 I Subdivision Name(if applicable) Section/Lot# Directions To Site: (`t{ W ,,!& - Sot N - Vee ,Il R✓1 # 13 If the answer to any of the following questions is 'yes", supporting docurn tation must be attached. Are there any existing wastewater systems on the site? ;Y! es DNo Does the site contain jurisdictional wetlands? Pvcs [?<oo Are there any easements or right-of-ways on the site? I "es *No Is the site subject to approval by another public agency? DYes fTNo Will wastewater other than domestic sewage be generated? DYes 8No IF RESIDENCE FILL OUT THE BOX BELOW # People# Bedrooms 3— # Bathrooms 2_ Garden Tub/Whirlpool DYes ANO Basement:. Yes o Basement Plumbing: DYes MO IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: Conventional ❑Accepted ❑Innovative DAltemative ❑Other Water Supply Type: D County/City Water D New Wellxisting Well D Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? D Yes If yes, what type? D No This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and 11 ing or staking the house/facility location, proposed well location and the location of any other amenities. 45� Property owner's or owner's legal representative signature Site Revisit Charge Date(s): 12.-1-I t{ Client Notification Date: Date EHS: Sign given DYes DNo Revised 11/06 Account# Invoice # � � i � -�. � oo��� y �w� � ---- � -- - -_ _ - - �--- - ----- , ,_ , - --- - - - - - , ; � i .r � � � , � � � . 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