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260 Stage Coach Rd ` " ��"' HEALTH DEPARTMENT RELEASE Foro�ceuseon�v *CDP File Number 158683- 1 .�n,,�a Davie County Health Department �z-ooaoaozo vd W'r yn � � 210 Hospital Street County ID Number: T-� _ � f''' P.O. Box 848 � � ' Evaluated For: HDR/WWC �"`����'' Mocksville NC 27028 Phone: 336-753-6780 Fax:336-753-1680 PERMIT VALID Z � � � g / a 0 1 9 UNTIL: Applicant: Susan Evans Property Owner: Susan Evans Address: 260 Stage Coach Rd Address: 260 Stage Coach Rd Ciry: Mocksviile ��ty� Mocksville State2ip: NC 27028 State2ip: NC 27428 Phone#: ��36)492-2765 Phone#: (336)492-2765 Propertv Location 8 Site Information Address260 Stage Coach Road Subdivisian: Phase` Lot: Road# Mocksville NC 2702$ SINGLE FAMILY Township: 'StfUCtuf2: Dlrections #of Bedrooms: 2 #ot People: Right on Valley Rd.left on Hwy 64 W, Left on Davie Academy Rd.then right on Stage Coach Rd. 'Water Supply: N/A Basement: �Yes�No Type of Business: Total sq. Footage: No.Of Employees: "Proposed Improvement: Addition "Release Conditions a � This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system senring the site will continue to function for any period of time. ApplicanULegal Reps. Signature Required? QYes ONo Appticant/Legal Reps.Signa#dre• 'Date; � � 'Issued By: 2�40-Nations,Robert •Date of Issue: 1 41 � 0 8 � a 0 1 4 ``-----� �. Authorized State Agent: ��� �� �— '�'�Site Plan/Drawing attached.*'� OHand Drawing almport Drawing • • HEALTH DEPARTMENT RELEASE rtswFa Davie County Health Department CDP File Number: 158683 - 1 �� ,�n��, � , � 210 Hospitat Street J2-000-00-020 � �' � ��' P.O.Box 848 County File Number: +� J `� � � Mocksville NC 2702$ Date: 1 0 / 0 8 / a 0 1 4 . �r�Mxao�K� �` Q Inch Scale: , pBiock = ,ft. Drawing Type: Health Department Re(ease QN/A _ _ _..; . � .� - C.�..�'J� j� , , , � � � , _. '��: _ � � ___ _ , �' � , �; : _ � �' r �� : _ _: , �� _ , _ _ _ ,, � ; _ : �__ _� : . . � _ , _� . _ _ - _ -��-- : _ ,� _ . , � � . : . � �dr �� � a� � � � � a� . . : . . : . . , . � , � � � � . , � � . , , . r . . . . . ...L..�.., . . . , :. . .. . . .. .... . . .. I : . � ,a. . : .. . . . ... . . . . . ,� . . � �. � ' ; � .. , . . � ' . � . . � ; : ., �. '. . . • � . , , . . .. . . . . . .. . . . .. . . . . .. . . _.� I . . ... �. .. . � . . ,. . i . �. . . .. . . . ... . . . . . . . . . . . . . ... . . . � . .. . � i � .i { � ' . � . . . � , . � .. ... . . \�... � . ... .. : . .. i .. . .. -. .. . . � . . . ._ . .. . �:...... � . . �� . . . o . .. . , , . i , � � . . . , i ' �, . ' i i � . . ; � ' . , . i , . � � � ., e . 1.. .�. . ....'� . . . . . ( . . . . .. � � ! � . I . . � . . . .. . .. . � . . . . .. . . . . . . . � . .. .. .. . . � . .... - . . .. .. . . . .. Page 2 of 2 i , , _� . ` Davie County Health Department �o�i 6l�' Environmental Health Section �F.-;. �l - 4 x;�� P.O. Box 848 �: '' C� �� RECEIVED 210 Hospital Street PAID ' ���� � : p�, ��, Courier# : 09-40-06 Date: Z_��t1. __� .� i��-; Date; C( 7�(o J Mocksville, NC 27028 Recetved by: !"�1M Phone:(336)-753-6780 �I�"� n Fax:(33 753-1680 ON-SITE WASTEWATER CERTIFICATION l.l�xx�I DP�e ��� (Check One) Replacement Remodeling Reconnection Name• / Phone N ber�,��o—'�� ����5 (Home) Mailing Address: � e 4-C-� (Work) , �-y-� � / 1 � Email Addres • $ � ,c�,,,,.� Detailed Directions To Site: /✓i'� �d � -� c_�o� A�,4�.�11�G� �i��i�� �2'0o0—Od 7A Properly Address: � �Q Z� � Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Type Of Facility: , �s1�C�- Date System Installed(Month/Date/Year): �a 1� Number Of Bedrooms:�_Number Of People:�_ . Is The Facility Cunently Vacant7 Yes N� If Yes,For How Long? Any Known Problems? Yes N� If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: ��1 ,p i Number Of Bedrooms:�_Number of People�_ Pool Size: Garage Size:� (c,�,,.1'r Other: Requested � Date Requested: � "o� �o -� !� (Signa re For Environmental Health Office Use Only Approved Disapproved . Comments: Environmental Health Specialist Date: *The signing of this form by the Erivironmental 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: - Paid By: Received By: � Account#: �j�l0 tS 3 Invoice#: �v � . . j , 1 g� �� r - ��,���� ,, _ ���� � ;I `� ��.�!t,� I ,��- ,t: n�"�. o��y� = Printed:Sep 26, 2014 All data is provided as is without warranty or guarentee of any kind either expressed or implied including but not limited to the implied warranties of inerchantabiliry or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie.North Carolina. its agents,consultants,co�tractors 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. J .* Appraisal Card �T Page 1 of 1 ' C�V[lCOUNT'Nt f0]fOt1f0�]]�t1�M RUMPOAVlD1�LLENf0. 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