497 Amber Hill Rd _ HEALTH DEPARTMENT RELEASE For Office Use Only
*CDP File Number 137337-1
.•sr o Davie County Health Department M Ail C4
210 Hospital Street �I(( ,(� B�-000-oo-ots
„ 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 4 / 1 1 / .1 0 1 9
UNTIL
Applicant: Tood Marshall Hall Property Owner. Tood Marshall Hall
Address: 497 Amber Hill Rd Address: 497 Amber Hill Rd
City: Yadkinville City: Yadkinville
State2ip: NC 27055 State2ip: NC 27055
Phone#: (336)492-6242 Phone#: (336)492-6242
Property Location&Site Information
res=Aill Rd Subdivision: Phase: Lot
NC 27055
SINGLE FAMILY Township:
`Structure: Directions
#of Bedrooms: 2 #of People: Hwy 601 North Tum left on Liberty Ch Rd.go all the way to church,
tum onto 011ie Harkey Road.go 1 mile tum right on Amber Hill Rd.
water Supply: NIA Place at the county line.
Type of Business.
Basement: �Yes n No
Total sq.Footage: No.Of Employees:
'Proposed Improvement:
Replace MH
"1 ::1
.Release Conditions c„
Ru
Maintain 5'setback from septic area.Refrain from driving over septic area. 6,
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? QYes ONo
Applicant/Legal Reps.Signature: *Date:
*Issued By: 2325"Mitchell,Brittany _ *Date of Issue: 0 4 / 1 1 / 2 0 1 4
Authorized State Agent:
*Site Plan/Drawing attached.**
' C5Hand Drawing 0Import Drawing
Davie County Health Department
q
1836 Environmental Health Section
P.O. Box 848
210 Hospital Street Dari. C�j�
I}}r .{yf {� _'q -� Courier ff : 00-40-06 �'�
V a` .. 11®��. 3
Mocksville, NC 27028
ReceivedD � -
Phone:(336)-753-6780 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: O Phone Number 3 3 V 5 Z- G 2 yome)
Mailing Address: �-� ��e-r�� 1� t� (' -6G " 92 t' 9 Z- (Work)
ar
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Email Address: Vx0 XX C (2. U cz , iie+
Detailed Directions To Site: ko G\ �zomY,5v` c� LAS \f O r1
01
Property Address: r4xb L r t ." lv
Please Fill In The Following Information About The EXISTING Facility: f
�Name System Installed Under: e pAl 00, adi Type Of Facility:�l mo
Date System Installed(Month/Date/Year): ? Number Of Bedrooms: _(27 Number Of People:_
Is The Facility Currently Vacant? Yes If Yes,For How Long?
An Known Problems? YesoZZ
s,Explain:
Please Fill In The Following
Information About The NEW Facility:
Type Of Facility:1gg,`j J W iY� A Number Of Bedrooms:_4-,2 _Number of People_
Pool Size: Garage Size: Other: tI. Lt
x Requested By: Date Requested:
ignature) �
For Environmental Health Office Use Only
pproved Disapproved
Comments: �e P� S"�edb�c G� Yyl S PYJ�i C Q ye a
Environmental Health Specialist Date: q- -
*The signing of this form by the Environmental t4ealth 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 hec, Money Order # Amount:$ /[fin,V Date:
Paid By: Received By:
Account#: Invoice#:
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