347 Granada Drive Lot 102. V% HEALTH DEPARTMENT RELEASE
e*46 Davie County Health Department
.. 210 Hospital Street
P,0.13ox 848
Mocksville NC 27028.
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Cleo Keaton
Address: 347 Granda Dr.
City:
State2ip:
Phone #:
Advance
NC 27006
(336) 403-8644
For Office Use Only
*CDP File Number 187249-1
County ID Number:
Evaluated For: HDRMWC
PERMIT VAUD 1 a/ 3 0/ 2 0 1 9
UNTIL:
r
Property Owner: MILLS GLENDA CORNATZER
Address: 2300 Laura Duncan Rd
City: Apex
State0p: NC
Phone #:
Property Location & Site Information
Address347 Granada Drive Subdivision: LaQuinta Phase: Lot: 102
Road # Advance NC 27006
SINGLE FAMILY Township:
'Structure: Directions
# of Bedrooms: 2 # of People: Hwy 64 East, left on Comatzer Rd. Left on Beauchamp Rd. left into
LaQuinta,'to end of Granada on left
'Water Supply: PUBLIC
Basement: n Yes D No
"Proposed Improvement:
Replace MH
Maintain 5 foot setback to any portion of the septic system
Type of Business:
Total sq. Footage: No. Of Employees:
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;
*Issued By: 2140 -Nations, Robert
Authorized State Agent: "I
"Date:
*Date of Issue: I a% 3 0/ a 0 1 4
**Site Plan/Drawing attached.**
3 Hand Drawing 0Import Drawing
Davie County Health Department
U
1836 Environmental Health Section ,
P.O. Box 848
,tom. A� 210 Hospital Street �W
Courier, #: 09-40-06 +, ;
maw: Mocksville, NC. 27028
ece�`eab '
Phone: (336) - 753 - 678 Fax: (336) - 753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: 4 a 4Q n Phone Number w 7 lQ 7 (Home)
Mailing Address: W7 r Work)
e Email Address:
Property Address:
Please Fill In The Following Information About The EXISTING Facility:
Type Of Facility: 5 GU f V L E
Name System Installed Under:
Date System Installed (Month/Date/Year): �q ((D /S
Number Of Bedrooms: Number Of People:_
Is The Facility Currently Vacant? Yes No
Any Known Problems? Yes No If Yes, l
If Yes, For How Long?
Please Fill In The Following I�n1formation About The NEW Facility:
Type Of Facility: Number Of Bedrooms:--2--Number of People_
Pool Size: Garage Size: Other:
xRequested By: A44&V �. Date Requested: /J
(Signature)
For Environmental Health Office Use Only
Approv Disapproved
Comments:
A
Environmental Health Specialist ,,-,-I�-ate:�/,Q -- —�Pd
*The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee
or limited) that the on-site wastewater system will function properly for any given period of time.
Check
Money Order #.
Amount:$ Q , Q 0 Date:
Paid By: Received By:_
Account #: Invoice #:
W 323
2171
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1.00
4838
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306
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2.501
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14,307
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9925
Printed:Dec 16, 2014
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