510 Underpass Rd ` �` HEALTH DEPARTMEN T RELEASE �'or ot�►ce use t�ntv
"'CDP File Number 194767-1
���n,►,t.o Davie County Heatth Department
,�,. � 210 Hospital Street County ID Number.
� � P.Q. Box 848 HDR/WWG
- ,�
'�. ,�� Evaluated For:
���"' Mocksville NC 27U28
Phone: 336-753-678� F�x:336-T53-1680 �'��M�r�A�� 0 a 1 1 1 1 a 0 a 0
UNTI L;
Appiicant: Josh Nifong F'roperty t3wner: Danny Chandler
Address: 2pQ Sc�uth Village Drive Address: 510 Underpass Rd
Ci�Y. Winsfon-Salem ���Y� Advance
State2ip: {�G 27127 State2ip: NC 27006
Phone#: E336) 764-a000 ph�ne#:
�roperty Location&Stte informatian
Address��a Underpass Rd 5ubdivisipn: Phase; Lot:
Road#Advance NC 27006_
SINGLE FAMILY Tovunship:
*Strutture: Dtrecttons
#of eedrooms: �af People: hwy 64 East,left on Hwy 801,to Underpass Rd at the Flower Shop,on
nght past Bailey Rd
'Water Supp�y; �A
Type of Business:
Baseme�t: �Yes❑No
Total$q. Footage: No.Of Empioyees:
"Proposed Imqrovament:
Bedroom and 6ath Plus Sunrpam
"R�elease Canditlon: i
The original perroit was written ofr 2 bedrrams.Two bedrroms witt be ihe end result af the proposed const�uction.The exixting se}atic system ;
is sufficient by design to serve the proposed addition.
This release in no way expresses or implies that the existing subsurface sewage treatment and disposal
system serving the site will contir�ue to function for any period of time.
Appticantll.egal Reps.Signature Required? UYes �No
ApplicanULegal Reps.Sigr�ature• 'Date: � �
- *lssued By: 214p-hlations,Robert *Date flf lssue: g � � � � � a 8 1 5
....Auth�nzed Stat�Agent:
�'*�ite P1an/Drawing ��tached.�'*
�� ��` t�Hand Drawing C71 mport Drawir�g
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c�j � �,� u� :� ��b.�ra �
Davie County Health Department
�V�a r�' vE�D nvironmental Health Section e� °
1 ,,.. .,, .
,�,. � � �'�"'� P.O. Box 848 � ; � '.
� �`" .;��"�. I�,�,,� ''� 210 Hospital Street '`�*",,';�
��
{� �;, �� Courier# : 09-40-06 <�,.:;
tl' 1`t . '.
Mocksville, NG 27028
Phone:(336)-753-6780 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
�
�3c, - q,y-ZSi� �EC..L
Name���'.�-µ �( �N�-, Phone Number .33C-� " �h� 8��-� (Home)
Mailing Address:�a,� s,,�a-.� V���e�-.� �� 3 3� � 7��- �'g� (Work)
C�i�usr�ti -Sac.F_� �G 2��2'7 Email Address:����j�(1 ��2TT./���'
Detailed Directions To Site: {�W`r �� � ����,, �-E� i4�T� [- l� �J ��N L� ��� �c�'
L��T �'N /.�./J�c l��d'SS i -{�l o/k-C o/�1 �-J C�K �'
Property Address: 5(o L�.-►�a c'2-'�i a-�-5 e�- .��.� ��✓a nJ G� N �- 2-'7�G� - -
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: Type Of Facility:
Date System Installed(Month/Date/Year)? ��,�� Number Of Bedrooms:�Number Of People: �
Is The Facility Currently Vacant? Yes No If Yes,For How Long?
Any Known Problems? Yes No If Yes,Explain:
Please Fill In The Following Information About The NEW Facility: �,,i���l ,�Ql d'�j���-�
Type Of Facility: ,� ?( ��n 'r Number Of Bedrooms:�Number of People �
Pool Size: Garage Size: Other:
RequestedB3. �--� DateRequested: � - Z? " �S
(Signature)
. 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..
Paymen • Cash Check Money Order # Amount:$ Date:
Paid By: Received By:
Account#: �� 6 7c�'� Invoice#:
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All data fs provided as Is without warcanty or guarantee of any kind either ezpressed or implied including but not Iimited to the implied nO� ��
� , � warranties of inerchantability or fitness for a paRicular use.All users of Davie County's GIS website shail hold harmless the County of U N
' Davie,North Carolina,its agents,consuitants,contractors or employees from any and ail claims or causes of action due to or arlsing out pri nted:J a n 29 2015
tv of the use or Inability to use the GIS data provided by this website. �
r �"�__'� ' •��� 5��� DAVIE COUNTY HEALTH DEPARTMENT J�� ����.r `��� �
� , (Septic Tank) Improvements Permit and Cert�cate of Completion �
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(Ground Absorption Sewage Disposal System - G.S. Chapte� 130-Article 13C)
OWNER OR CONTRACTOR _ �i`�e.�t�J� C �� rl t��;���:. a<. DATE rt 'f�I v� PERMIT
F
LOCATION ��c.�;t r9 t�c i� t `_ �_. �.+ ' �TQ p n ry
, , lr 07 (
-.�-.,i i� �. S.R. N 0. -'t, �:-
SUBDIVISION NAME LOT N0. SECTION OR BLOCK N0.
HOUSE ❑ MOBILE HOME $USINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
N0. BEDROOMS �_ N0. &1THROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO Q' Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES ❑ NO [a• Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES �' NO ❑
SITE SUITABLE � YES [�+ NO ❑ �
SIZE OF TANK G�� _ gal.
. �' r ,. , .,' �y:�.
NITRIFICATION FIELD sq. ft. �`�:', ,�r .;'� 1��'`'� � �
DEPTH OF STONE IN LINES: �rf' +����'�'� .
WATER SUPPLY: Individusl Q� Public ❑
IMPROVEMENTS PERMIT BY �,,.�;_ ; ' �f��,�,-..��_} INSTALLED BY QQ �e�. �
;
CERTIFICATE OF COMPLETION BY Date �`��` 7�
(8/16/73) �Construction must ply with all other applicable State and local regulations
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