141 Sally Ln HEALTH DEPARTMENT RELEASE ; Fo�offceuseo��vJ - `
*CDP File Number 219180 1
a..�„�, � Davie County Health Department
a�'' ",.." ,_ �
.. � � 210 Hospital Street Coun ID Number :
� Y� �{ t''` ,
P.o. Box 848 -HDR/WWC
'� y �,_ � Evaluated For�.
'`��-d'' Mocksville NC 27028
Phone:336-753-6780 Fax:336-753-1680 PERMIT VAUD H 6 / � 7 / a 0 1 6
UNTIL:
Appiicant: Bobby E. Robbins Property Owner: Bobby E. Robbins
Address: 141 Saily Lane Address: 141 Sally Lane
City: Mocksville Ciry: Mocksville
State2ip: NC 27028 State2ip: NC � 27028
Phone#: (336)909-1834 Phone#: (336)909-1834
Propertv Location 8 Site Infortnatton
Address�41 SallyLane . Subdivision: Phase; Lot
Road# Mocksville NC 27028
SINGLE FAMIIY Township: _
'SUUCtU�e: �irections
#oi Bedrooms 3 = ��` - " #of Peopte: - �- = - Hwy 601 S.left on Deadmon Rd,right on Witl Boone Rd.Satly Lane on
the left
'Water Suppiy: PUBLIC
--- Type of 8usiness: " -
Basement: �Yes❑No
Total sq.Footage: No.Of Employees:
"Proposed improvement: --
Repiace MH
'Releaso Condittons - �
I was unable to locate the system with a probe of 4 foot.7he contractor installing the home must insure that the home is a minimum of 5 feet
from any portion of the septic system --.
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? 4Yes ONo
ApplicanULegal Reps.Signature• *Date; � �
*Issued By: 2�4o-Nations,Robert *Date of Issue:_ 0 6 / !b � � a 0 1 6
Authorized State Agent:
**Site Ptan/Drawing attached.**
`±`�,''� U Hand Drawing Olmport Drawing
HEALTH DEPARTMENT RELEASE
da�s��4 Davie Counry Health Department CDP File Number: 219180 ; 1
� �, 210 Hospital Street
� �` ' P.o. Box sas County File Number:
� - ;.
�,� �• " Mocksvilte NC 27028 Date: 0 6 / 0 7 J a 0 1 6
1��'
'�a n v� . .
'`�°�""�" Olnch
Scale: OBlock — .ft.
Drawing Type: Health Department Release � �N/A
,
---.
�
.�.r �
_ _ � �
�
;�_ _ �.__.__.,
s
---�-.- ,� �z
,
_ .�-� s , , �► s �;
jt-.----t-,�._-1�.-t-t--� _'r _
,
�
r� -._ :
�-� ;_
� ,
�
�
_ _
�- �
1
� �
'� !
�
;�
�
�
��
___ __�_ _
_ . �._ _� _ 1. __
Page 2 of 2
' , ' r . , Y� �VI I• •'I • • 'W Y /
Da�ie County Health Department
���f� r. � En � onmental Health Section '���;,q, .
� , �atet � I P.O.Box 848 � �:
�1
;,�
� ;�, �� ' ` 210 Hospital Street � " � �
C"� . _ �'
p U�� Couner# : 09-40-06 �c���
Mocl:sville, NC 27028 �
Phone:(336)-753-6780 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
VJ��� �--� , db. ;ns PhoneNumbe��� ��D/�
Name: (Home)
Mailing Address: � �� 33� Q�"��3T � (Work)
,/111 ack���ll� �UC �,7az� 336 gs�0�3L�
Detailed Directions To Site: -�GS �i �� � N
1I,600 P� C�6 /� �'.
Property Address: � . �� � !9/1/f�
Please Fill In The Following Informatio o XISTING Facility:
Name System Installed Under: Q�� ������s Type Of Facility: �����
Date System Installed(Month/Date/Year): �� /7i�2%�"iv�LNumber Of Bedrooms:�5 Number Of People: /
Is The Facility G�rrently Vacant? Yes No If Yes,For How Long?
Any Known Problems7 Yes N) If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: J wrn�' �vt"� Number Of Bedrooms:_�_Number of People
Pool Size: : Garage Size: Other:
Requested By:�,,�Q_ .� � � / Date Requested: ���`�lti
ignature
For Environmental Health Office Use Only
Approved Disapproved
Comments:
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.
Payme : Cas Check Money Order # Amount:$ /dd, C1 Date:
Paid By: Received By:
Account#: a _` � Invoice#:
�'�`� . � . � 2g28 � ��yo
- `� �
��152 � � �419 �--""�
;,� �� o ���(730) 4 �.� �'�
' , � �$��,� ��,. �r8 __ 11
���� ��� ` �� ��1844_ ' � _�4 �-� ,
_ �.'�� � ��� , F� ,�� �- a -_
f;r"�—...�•--...�_.,.�yl �� � �'413`� �' ' ,-----�--- _,
i '-�--_.._ ----.._1�.. �� �118� ��.
(.J��1 ti � ,' -36 1 �� �a�6d o
x ���t� ��---„` _.� r �.,, o
� ,- �-.1.� �`~_� � 411
<`r �''�.��45. ��� ``---• t: '�-=��-I
��� � .� y -- �
'�'�---...J � �^�,_ ,
� ' � - _._
_. �'�"--�-�---',����'�~ .P
_ ... _- '1023
-, 59 c�,
�85 _ _
� _ ---.��U��L 436
� � �` �--�-,��-�------= �"`� �,j' - - _._....____.__�.,___�_.-
� E �,:� � ,��i �'���l �._ --'
.� --"��';128 ���
C�-0�� oo �� �
� W' � �� �_.��
7672 �.� � � �
�
�G40
�. ' o�'"�'°�F
All data is provided as is without wartanty or guarantee ot any kind either expressed or implied Including but not limited to the implied wartanties oi �, � ,�
��� � merchantabiiity or fitness for a particular use.All users of Davie County's GIS website shail hoid hartnless the County of Davie,North CaroGna,its �U N�
' agents,wnsultants,conVadors or employees from eny and aA claims or causes of action due to or arising out of the use or inabiliry to use the GIS pri nted:M ay 18 2016
S data provided by this website. �
� . . , _.,� �� / �
`.�,�-_
��o (1 -�-``_-_--_�
c� ���.
�, J � ���
T, �, s
��.J�,`J � ��r
i��• � � �9 p ~ •�� '
� � s' l;'IYJ �
��� �� ������"' i�"�
• f �
� ti,,,,,,,,� A.� , � t -�__�___`� �,
� ���
--_.� �'' � ^+�.. ,�, „-� �.
_ J� __"+�—._�_h_�_y �� � tp� —„_„� I "4
' � i S ���.�'.t"""......�
Ir ' �
/ •r l
', '---�-,..._�.�.._-- ;i'CN '� ,�
j �r f,' " �� l � ! fjg.
� _� � " 'f �-^
I � - r' ��` _.���M1 r',
� x :141- """-,...� � `` �
z-��� �fl' --._�i�
� ' � � f _.~�
� a,.��:,,,,`145N'� :1 �_3�,r _
� o��- ., All data is provided as is without wartanty or guarantee of any kind either expressed or(mplied inGuding but not limited to the implied wartanties of �, ,�
��� � merchantabiliry or fitness for a particular use.All users of Davie Countys GIS website shall hold hartnless the County of Davie,North Carolina,its �U N�
"�. agents,wnsultants,contractors or empioyees from any and ap cWims or causes ot action due to or arising out of the use or inability to use the GIS pri nted.M a 18 2016
S data provided by this website. Y �