1401 Peoples Creek Rd (2)/1 11 HEALTH DEPARTMENT RELEASE
Applicant:
Address:
City:
State/Zip:
Phone #:
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Warren Reynolds
1401 Peoples Creek Rd
Advance
NC 27006
For Office Use Only
;CDP File Number 187321 -1
County ID Number.
`Evaluated For HDR/WWC
PERMIT VALID 1 a/ 3 0/ a 0 1 9
UNTIL:
I-
Property Owner: Warren Reynolds
Address: 1401 Peoples Creek Rd
City: Advance
State/Zip: NC 27006
Phone #:
Property Location & Site Information
Address 1401 Peoples Creek Road Subdivision:
Road# Advance NC 27006
Township:
Directions
Hwy 64 East, left on Hwy 801. Go to 2nd Peoples Creek Rd. In
Advance, beside Flower Shop, take right. property on Right
'Structure: SINGLE FAMILY
# of Bedrooms:
'Water Supply: N/A
Basement: F� Yes ❑ No
'Proposed Improvement:
Pool
# of People:
Maintain 15 foot setback to any portion of the septic system
Phase: Lot:
Type of Business:
Total sq. Footage: No. 4f Employees:
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
Applicant/Legal Reps. Signature: 'Date:
'Issued By: 2140 -Nations, Robert *Date of Issue: 1 a/ 3 0/.2 0 1 4
Authorized State Agent:,
**Site Plan/Drawing attached.**
(@Hand Drawing Olmport Drawing
Davie County Health Department
4 1836THEnvironmental Health Section
gam IV�p P.O. Box 848
. A'. �i C� 210 Hospital Street
0 Courier # : 09-40-06
Mocksville, NC 27028
Phone: (336) - 753 - 6780
Fax: (336) - 753-1680
ON-SITE WAS CERTIFICATION
(Check One) Replacement Remodeling Reconnection Av
-5.���
Name: MhW K VL)L O lot!�: Phone Number 3?6,2201 37 7 7 (Home)
Mailing Address: IVO I �a �l � S d i-^e-� k- Pe) (Work)
Ad x, �, �_ Email Address:
Detailed Directions To Site: i gv el ad l
Address: % P- E!!2511 e S L iG t~ ay
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under:
Type Of Facility:
Date System Installed (Month/Date/Year): 1d219" // 7 Number Of Bedrooms: ' Number Of People:
Is The Facility Currently Vacant? Yes `- If Yes, For How Long?
Any Known Problems? Yes 6�If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility` /: To C) t Number Of Bedrooms: Number of People
Pool Size:X Garage Size: Other:
�,equested By: Date Requested:
ignature)
For Environmental Health Office Use Only
Approved Disapproved
Co ts:
Environmental Health
zz-
*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: Cash - (Check) Money Order #
Paid By: C� Received By:_
Account #: ' i5 ��' I Invoice #:
Iv -VV A(;.
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D.B. 900. PG. 367
P.I.FL 5789-78-4430