711 Cana Rd HEALTH DEPARTMENT RELEASE For Office Use Only
*CDP File Number 81241 - 1
Davie County Health Department
F4000002802A
. t 210 Hospital Street County ID Number.
P.O. Box 848 Evaluated For: HDRNUWC
Mocksville NC 27028 l
Phone:336-753-6780 Fax:336-753-1680 PERMIT VAUD 1 1 / 0 a / a 0 1 7
UNIIL
Applicant: James C. Jordan Property Owner: James C. Jordan
Address: 711 Cana Road Address: 711 Cana Road
City: Mocksville City: Mocksville
State/Zip: NC 27028 State0p: NC 27028
Phone#: (336)998-3906 Phone#: (336)998-3906
Property Location 8. Site Information
Address711 Cana Road Subdivision: Phase: Lot:
Road# Mocksville NC 27028
SINGLE FAMILY Township:
`Structure: Directions
#of Bedrooms: 1 #of People: 1 601 North right on to Cana Road
'Water Supply: EXISTING WELL
Basement: n Yes❑No Type of Business:
Total sq. Footage: No_Of Employees:
`Proposed Improvement:
SF one bedroom cabin
'Release Conditions
keep building at least 5'from septic tank and drainlines
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. Signatures *Date:
*Issued By: 2244-Daywalt,Andrew *Date of Issue:• 1 1 / 0 a / a 0 1 a
Authorized State Agent:
**Site Plan/Drawing attached." TotalTime:(HH:MM)
�HandDrawing dlmportDrawing 1 "ours Minutes
HEALTH DEPARTMENT RELEASE
d'' 514 Davie County Health Department CDP File Number: 81241 - 1
210 Hospital Street F4000002802A
t
P.O. Box 848 County File Number:
Mocksville NC 27028 Date: 11 / 0 -1 / 2012
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Scale: O Biock
Drawing Type: Health Department Release ON/A
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