276 Powell RdHEALTH DEPARTMENT RELEASE
d..sr„rEo Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Richard Davis
Address: 276 Powell Road
City: Mocksville
State[Zip: NC
Phone #:
(336) 492-7753
27028
/ For Office Use Only
*CDP File Number 121787 -1
H3-000-00-032-99
County ID Number:
valuated For: HDR/WWC
PERMIT VALID 0 6/ 1 1/ 2 0 1 8
UNTIL:
Property Owner: Richard Davis
Address: 276 Powell Road
City: Mocksville
State/Zip: NC 27028
Phone #: (336) 492-7753
Property Location & Site Information
Address276 Powell Road, Subdivision:
Road # Mocksville NC 27028
Township:
Directions
US 64 West 6 miles west of 1-40 powell Road on left 1/2 mile on right
white triple wide, shed in back
'Structure:
SINGLE FAMILY
# of Bedrooms:
`Water Supply: N/A
Basement: E]Yes ❑ No
'Proposed Improvement:
2 story shed
# of People:
Phase: Lot
Type of Business:
Total sq. Footage: No. Of Employees:
It is the responsibility of the owner to maintain a 5' 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? Oyes QNo
Applicant/Legal Reps. Signature: *Date:
*Issued By: 2244 - Daywalt, Andrew ,,.�,__tl *Date of Issue: 0 6 / 1 1 / 2 0 1 3
Authorized State Agent: (A" A piJN/xAA—
**Site Plan/Drawing attached.** Total Time:(HH:MM)
0 1 Hours 0 0 Minutes
G Hand Drawing Olmport Dravving
4� r
Date:
Davie County Health Department
Environmental Health Section
RECEIVED
P.O. Box 848
210 Hospital Street
Courier # : 09-40-06
Mocksville, NC 27028
Phone: (336) - 753 - 6780 Fax: (336) - 751- 8786
ON-SITE WASTEWATER CERTIYICATION FOR DWELLING
(Check One) Replacement N.Remodeling Reconnection
Name:2 c (L(y v-e�' > / C, Phone Number d ' �% (Home)
Mailing Address: '.1-7 L Pd w -e(( ►='X (Work)
MDr,'�--S f/I t 1Email
Detailed Directions To Site:
1L,o -�f-- r., —V-. 1 2r c >k
Property Address: 9 %
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: X r' t " Type Of Facility:
Date System Installed (Month/DateNear): Number Of Bedrooms:ti —Number Of People:
Is The Facility Currently Vacant? Ye's If Yes, For How Long?
Any.Known Problems? Yes If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility:(, G f � Number Of Bedrooms:—Number of People_
Requested By: Date Requested: ��' � 9 " w�I r3
(Si re)
For Environmental Health Office Use Only
Approved Disapproved PAID
Comments:
Date:
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
(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Paymen . Cash Check Money Order # Amount:$) _Date:
Paid By: DA(// 5 Received By: /1 w
Account #: %� C� Invoice #:
C�,� # 1-21791-
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— — — — — ----------I----ld—_----ld __---ld-----ld_---_ fid -----a _--_—p—_—_-------q
276 POWELL RD, MOCKSVILLE
OWNER: RICHARD C DAVIS
APPLICANT: CRYSTAL DAVIS
POWELL RD
0 30 60 90
SCALE: 1"=30'