2439 Farmington RdHEALTH DEPARTMENT RELEASE
rssA,Fav Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant:
Victoria Rivers
Address:
972 Wyo Rd
City:
Mocksville
State/Zip:
NC 27028
Phone #:
(336) 940-2402
'CDP File Number 161802-1
B5.000.00.083.07
County ID Number:
Evaluated For: HDR/WWC
11
PERMIT VALID 1 1 / 1 3 / a 0 1 9
UNTIL
Property Owner: Lorin A and Karen Wood
Address:
City:
State/Zip:
Phone;#:
443`i Property Location & Site Information
Address Farmingtonm Rd Subdivision PhaseLoc.
Road m Mocksville NC 27028
MOBILE HOME Township:
'Structure.
_ Directions
of Bedrooms: 3 » or People. 4 Hwy 158, Left on Farmington Rd, cross Hwy 801 on left before #2455
`water Supply: NIA
Tvpe of Business'.
Basement. R Yes o No
Total sq. Footage: No. OI Emplovees.
'Proposed Improvement:
Replace MH
Maintain 5 foot seback 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.
Applicant/Legal Reps. Signature Required? OYes ONO
Applicant/Legal Reps. Signature: `Date: / /
2140 - Nations, Robert
Issued By: Date of Issue: 1 1 1 3 x 0 1 4
Authorized State Agent:f
**Site Plan/Drawing attached.**
OlHand Drawing Qlmport Drawing
6!
Phone: (336) - 753 - 6780
Davie County Health Department
Environmental Health Section
RRCEjVED P.O. Box 848
210 Hospital Streets
Courier #: 09-40-06 f.
Mocksville, NC 27028
Fax: (336) - 753-1680
ON-SITE WACTEWATER CERTIFICATION
'{ ( (Checic One) (! e`placemen�Remodeling Reconnection -
Name: )11(� j�') a \ V O.i`S Phone Number .,53(9 -q 4o-,zl-4o �- (Home)
Mailing Address: 9'7 Wig) _ -Rd (Work)
N1 oUC�/73 I��. Email Address:
Detailed Directions To Site: _ ak
901
& 1'iz
r m� r�.a'(Z1x�
d - nra�t'�riu�� ch. f Q,rm l ng+zr�
Property Address: 1-Irml'161M '-4:.td 1 0 5 -UUC) _0 - C)XS' V(
Please Fill In The Following Information About The EXISTING Facility: 1. 0 3
Name System Installed Under: pWoo ) :::� [)„�) Type Of Facility: r)-)14
J IQ -Date System Installed (Month/Date/Year): 147 IAi a I6'R Number Of Bedrooms: 3 Number Of People:
Is The Facility Currently Vacant? es i 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: MnH r_) nr- 4 In , o Number Of Bedrooms: Number of People S
Pool Size:l ( Garage Size: Other:
Requested By: Q�/Y /� �s b to Date Requested: 1 I"(� dq ) )4
(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.
Payment: Cash Check Money Order # allq C1. Amount:$ Date:
Paid By: J / Received By:
Account #: 6 6 0 2, Invoice #:- (0 (Q
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printed:Nov 06, 2014
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