123 Bridle Ln HEALTH DEPARTMENT RELEASE For Office Use Only
*CDP File Number 124015-1
Davie County Health Department
G$-aoaoo-ooi-oa
,. 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 1 / 1 3 / 2 0 1 8
UNTIL:
Applicant: Chris K Johnson Property Owner: Robert and Marsha Thompson
Address: PO Box 2132 Address: 123 Bridle Lane
City: Advance City: Advance
State2ip: NC 27006 State2ip: NC 27006
Phone#: (336)757-2568 Phone#:
Property Location&Site Information
CAddress 123 Bridle Lane Subdivision: Phase: Lot
ad#Advance NC 27006SINGLE FAMILYTownship:
ructure: Directions
#of Bedrooms: #of People: Hwy 158,tum right onton Highway 801,tum right on Mocks Church
Rd.Left on Beauchamp.To the end tum right,Bridle Lane on left
'water Supply: N/A
Basement: n Yes❑No Type of Business:
Total sq.Footage: No.Of Employees.
'Proposed Improvement:
Accessary building
'Release Conditions
It
is the responsibility of the owner to maintain a 5 foot minimum setback between the wastewater system and any part of the structure
foundation,including porches,decks,and any other appurtenances. If you are unsure as to the exact location of the septic system,please
have a licensed installer or inspector locate the septic system for you. The local county health department in no way implies that the
proposed construction meets the required setbacks from the septic system unless otherwise noted. This release only shows that this
property has an approved wastewater system that appears to have met the permitting requirements at the time it was installed.
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: 2244-Daywalt,Andrew *Date of Issue: 1 1 1 3 2 0 1 3
Authorized State Agent:
**Site Plan/Drawing attached.** TotalTlme:(HH:MM)
O Hand Drawing Olmport Drawing 0 1 Hours 0 0 Minutes
PAD
Date: /0 Z�l3
Davie County Health Depwrlment
4 18 j� Environmental Health Section -
i � P.O.Box 848
:•�
210 Hospit,-tl Sheet
Courier# :09-40-06
Z Mocksville,NC 27028
pate:
Phone:(336)-733-6780 Fax:(336)-733-1680
ON-SIT TFWATER CERTIFICATION
(Check On Replacement' Remodeling Reconnection
Name:._(_ '�k, Phone Number (Home)
Mailing Address: /;y, cv ,� Z( 2 3 Ln 75 7-Z S(o (Work)
//D 111 G Ztion�
Detailed Directions To Site:
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Property Address: t 3 13210e_E 11_401:. D✓A^jCf_" t'rt L�+:-125- 2i+c� - + 11�dRGis} �do,-APS CIAJ
Please Fill In The Following Information /4/About The EXISTING Facility:
Name System Installed UnderMARIM/2(d 00= DTs dt'i Type Of Facility: 71`511,Vn.t r'
Date System Installed(Month/Date/Year): /q q Number Of Bedrooms: Number Of People: 7—
Is
Is The Facility Currently Vacant? Yes ( c_ If Yes,For How Long? �gg-00 o -00'cc)1 -0
Any Known Problems? Yes N- If Yes,Explain: U
Please Fill In The Following Inf!o-�rmation About The NEW Facility:
Type Of Facility: Number Of Bedrooms: Number of People
Pool Size: IVJ� n //Garage Size: Z X 5 Z- Other:
Requested By: Date Requested:
(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 ed)that the on-site wastewater system will function properly for any given period of time.
Payment: Casoney Order # _Amount:$ Date:
Paid By: Check / 144 1 Received By:
Account#: 17 2 0/57 Invoice#: 0 r
c�J
CHRIS IG JOHNSON
(336)757-2568
chris.ckjbuilds@yadtcl.net
THESE DRAWINGS AND THE DESIGNS
REPRESENTED ARE THE PROPERTY OF
CKJ BUILDING&DESIGN,IAC.
REPRODUCTION OR USE OF THESE
DRAWINGS WITHOUT THE WRITTEN
CONSENT FROM CHRIS K.JOHNSON
EXISTING IS PROHBBITF.D.UNAUTHORIZED USE
GRAVEL DR. MAY DE SUBJECT TO LEGAL ACTION.
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EXISTING
HOUSE
SITE PLAN
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OCTOBER 23,2013
SHEET
1601 1 OF 3