193 Scenic Dr ,.�,, _ .___�rY HEALTH DEPARTMENT RELEASE Forot�Ge use o��v ..
`CDP File Number 197687-1
�d��.o Davie County Heatth Department
,�,. � 210 Hospital Street 'County ID Number.
� ' P.O.Box 848 ' HDR/WWC
�. �,`� .� Evaluated For.
'���"' Mocksville NC 27U28
Ph�ne:33fi-753-6780 Fax:336-753-1680 PERMiT vAuO 1 0 / a H / a 0 a 0
. UNTII.:
Applicant: Gina W. Smith Property Owner: Gina W. Smith
Address: 808 Davie Academy Rd Address: 808 Davie Academy Rd
C��Y: Mocksvill3 ���Y� Mocksvill3
State2ip: NC 27028 State2ip: NC 27028
Phone#: (336)745-5788 Phone#: (336)745-5788
Propenv Locatlon 8 Site Information
Address�93 Scenic Orive Subdivision: Phase: Lot
Road# Mocksville NC 27028
SINGLE FAMIIY Township:
`Structure: DirecUons
#of Bedrooms: 3 st ot Peopte: Take road beside Ingersoll to Scenic on left
'Water Suppty: �A
Basement: �Yes a No Type of Business:
Total sq.Footage: No.Of Empioyees:
'Proposed Improvement:
Replace Home
"RN�as�Condklons ;
Miaintain 5 foot setback to 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.
AppticantlLegal Reps.Signatu�e Required? OYes ONo
Applicant/Legal Reps.Signature: *Date: � �
: 2140-Nations,Robert *
Issued By: Date of Issue: � � a 0 a 0 1 5
Authorized State Agent: �
4. .
**Site PIan/Drawing attached.**
`� r�� C�Nand Drawing Olmport Drawing
�� . �..� .., ���rp.e�cuo�lc— Cos-F ! �
Davie County Health Department
��is f� vironmental Health Section �
�.�� .
;�: � : � „�CF,1V � P.O. Box 848 � . �`
. .� � ';5,,, t� 210 Hospital Street � '
�U 13�' Date: � Courier# : 09-40-06 � 1 n i 1
Mocksville, NC 27028 �
y:w
Phone:(336)-753-6780 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: Phone Number�_s� ����1[O(4 (Home)
Mailing Address: � �//gZ,� (Work)
y- -
� ail Address:
Detailed Directions To Site: '1 � � � ..L/v '�il �`/
�v �eeu�c`r ,C� /'. r� !�e-P�
Property Address: � _��� �
Please Fill In The Following Information About The EXISTING Facility:
/ )
Name System Installed Under: l�i�1 Type Of Facility: �
Date System Installed(Month/Date/I'ear):���_Number Of Bedrooms: � � Num.ber Of People:
Is The Facility Currently Vacant? Yes No If Yes,For How Long?
Any Known Problems? Yes o If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: 1� W ��� `�1' Number Of Bedrooms:�_Number of People
'Pool Size: Garage Size: Other:
Requested By: �Gf�l/GfiT GG�'�0/�1 �%� Date Requested: /�'''5���
(Signa )
For Environmental Health O�ce Use Only
Approve Disapproved
Comments:
Environmental Health Specialist ate: �!!�'�� �.5
*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 . Cash Check Money Order # Amount:$ ' Date: -' S
Paid By: Received By:
Account#: Invoice#:
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s Printed:Oct 14, 2015
All data is provided as is without warranty or guarantee of any kind either expressed or implied fncluding but not limited to the implied
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North Carolina,its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out of the use or
inability to use the GIS data provided by this website.
._:. .�
�----. ���p�er worl�.- l,os-� f I
Davie County Health Department
��'s�� vironmental Health Section �
,...��..�._,., .
� "<�� �Cj'+,1v / P.O.Box 848 ''-•j
;�, 210 Hospital Street � �I.
� � �. ��� Courier# : 09-40-06 ' `�'
jj � Date: � MocksviIle, NC 27028 �� �n �1
,#�,
Phone:(336)-753-6780 Fax: (336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
' •(Check One) Replacement Remodeling Reconnection
! � � �� ���- �'�
Name: � Phone Nutnber (Home)
Mailing Address: � ���l�sj, (Work)
. � ,
/ E ail Address:
Detailed Directions To Site: (� � �, � .�N -�P a C/
� �U J eP1�/l (` �U �. Y�/ �-P�G
Properly Address: � ��f�. ' /�.
Please Fill In The Following Information About The EXISTING Facility:
I j �/j�
Name System Installed Under: �i I�1 'Type Of Facility: /��
�
Date System Installed(Month/Date/Year): j�'��_Number Of Bedrooms: � � Number Of People:
Is The Facility Currently Vacant7 Yes No If Yes,For How Long7
Any Known Problems? Yes o If Yes,Explain: � �
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: k✓ �V ��� `� Number Of Bedroonns: � Number of People
.
'Pool Size: Garage Size: Other: '
Requested By: L%�i(/(,�i7GGf'�0/J /'/ % Date Requested: �C�''J��5
(Signa )
For Environmental Health Office Use Only
Approve Disapproved
Comments: �
Environmental Health Specialist '� �ate: !�'�� �.5
*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 . Cash Check Money Order # Amount:$ ` Date: -' s
Paid By: Received By:
Account#: , Invoice#:
.��f�,►�. /.�� � s..�` y�,d S4