186 Valley Oaks Drive Lot 10HEALTH DEPARTMENT RELEASE For Office Use Only
*CDP File Number139260 -1
Davie County Health Department
B7 -140 -AO -014
210 Hospital Street County ID Number:
' P.O. Box 848 HDR/WWC
Evaluated For:
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID 0 6 a 4 a 0 1 9
UNTIL:
Applicant: George Tucker
Address: 238 Brier Creek Rd.
City: Advance
State/Zip: NC 27006
Phone #: (336) 403-3578
Address 186 Valley Oaks Read s' J �Fe
Road # Advance NC 27006
*Structure: SINGLE FAMILY
# of Bedrooms: # of People:
*Water Supply: N/A
Basement: F—] Yes ❑ No
*Proposed Improvement:
Sunroom
Property Owner: Charles Moilholen
Address: 186 Valley Oaks Road
City: Advance
State/Zip: NC 27006
Phone #:
Valley Oaks Phase:
Township:
Hwy 158 or 1-40 East, take 801 North, right on Yadkin Valley Rd. the
right on Valley Oaks Road
Type of Business:
Total sq. Footage: No. Of Employees:
Ch—cten
Remaning
750
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 ONO
Applicant/Legal Reps. Signature: *Date: /
*Issued By: 2140 - Nations, Robert *Date of Issue: 0 6 / a 4 / a 0 1 4
Authorized State Agent: U "^
**Site Plan/Drawing attached.**
Hand Drawing O Import Drawing
L
Drawing Type:
HEALTH DEPARTMENT RELEASE
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Health Department Release
CDP File Number: 139260 - 1
County File Number: B7"140 -A0-014
Date: 06 / .24 /.2014,
O Inch
Scale: O Block :,-_ft.
O N/A
Drawing Type:
HEALTHDEPARTMENT RELEASE
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Health Department Release
Page 2 of 2
CDP File Number: 139260 - 1
County File Number: B7"140 -AO -014
Date: A 6./. 4/ a 0 14
j
,r- Davie County Health Department
'V ng 6j ' Environmental Health SectAtc
.: "! pAID P.O. Box 848 : 61,�+'j��,+D
210 Hospital Street ze'
��7 L Courier # : 09-40-06
e Mocksville, NC 27028
Phone: (336) - 753 - 6780
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Fax: (336) - 753-1680
Name: OPS LIC cK {r -1-/Phone Number 3(2 - U '3S 78 (Home)
Mailing Address: �3� 1�l � i Py 0,1rct D c{ (Work)
Vc�wc Email Address: +L - fir CC) kilo,+ P fill C1
Detailed Directions To Site:
Property Address: % e -f6 12e, 11-e 0a k 5 %S
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: Type Of Facility:
Date System Installed (Month/Date/Year): x 'T 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:
Type Of Facility: !!!�m 0 (2h / -�'z4n EL2 o G� a KL -2 Number Of Bedrooms: Number of People
Pool Size: Garage Size: Other: /
Requested By: Date Requested:
(S' natur
For Environmental Health Office Use Only
ApproveSl/ Disapproved
Environmental Health Specialist
Date: 6 – aZ y — l
*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.
Payment: Cash //Checv Money Order #
Amount:$- jm . (m Date:
Paid By: IQ Received By:_
Account #: ( 12(Q Invoice #:.
186 VALLEY OAKS DRIVE
_ 118.00'
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PROPOSED
SUNROOM
EXIST. ---�
SEPTIC TANK
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DWELLING
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118.00'
EDDIE MILHOLEN
,JOB NO. 108-14 DRAWN BY —<BH --
SCALE 1 "=50' 1 DATE 6-19-14
SITE PLAN
DRAWING NO.
PLAN # SUNROOM 1 OF 1
EXIST. DECK
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name —,—fr m _+_m 7-Tiu rm6J Yt" Date
Location
Subdivision Name � khA 00,JA j Lot No. �Q Sec. or Block No. - /
Lot Size l (t.6 ' House Mobile Home _ Business -- Speculation V
No. Bedrooms _, No. Baths No. in Family
Garbage Disposal YES 0 NO 0. Specifications for System: i0o
Auto Dish Washer YES a- NO
Auto Wash Machine YES Ll NO {]
Type Water Supply OOLMAk4
'This permit Void if sewage systei described below is not installed within 36 months from date of issue.
f
Improvements permit by
'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 X1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diag
System Installed by W �n P
�Z
b�-ac�sP
i .
Certificate of Completion L� Date
"The signing of this certificate shall indicate that the system describe bove has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way, be to en as a guarantee that the system will function
satisfactorily for any given period of time.
ks Of
V011Vj �'
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Name
Location
Date c -
Permit Number
Subdivision Name Lot No. Sec. or Block No.
Lot Size 1 House Mobile Home _ Business _— Speculation
No. Bedrooms No. Baths < No. in Family
Garbage Disposal YES ❑ NO 0. Specifications for System:
Auto Dish Washer YES ❑' NO ❑
Auto Wash Machine YES 0'' NO ❑
Type Water Supply - ---
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
1
l 1
Improvements permit by
.i
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram:
System Installed by
Certificate of Completion Date
*The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIL COMITY HEALTH DEPART MIT
ENVIZOT1iMTTAL HEALTH SECTION
SOIL/SITE. EVALUATIO17
PAIS DATE Z7Z
ADDRESS
p u c, LOCATIO14 CfA�/C•� dv/ / �
LOT SIZE //&"")(J f
TOPOGRAPHY: �f
SOIL TE:,TURE *. S
SOIL STRUCTURE < S
DEPTH*. 5 -
RESTRICTIVE HORIZOPS*.S
PERCOLATIOTT PATE:
2.
3.
Presoak
Bark & time
Drop Time
Pate/iii%. Inch
v'b
Fd
I
*CLASSIFICATIOTT*.Suitable Provis'onally Suitable Unsuitable
COLS- 1TTS *.