165 Childrens Home Rd For Office Use Only
HEALTH DEPARTMENT RELEASE
;CDP File Number 187250-1
Davie County Health Department
d r 210 Hospital Street County ID Number.
P.O. Box 848 HDRMWC
Evaluated For:
Mocksville NC 27028
Phone:336-753-6780 Fax:336-753-1680 PERMIT VAUD 1 a / 3 0 / a 0 1 9
uN nL:
Applicant: Eddie Church Property Owner: Eddie Church
Address: 165 Children's Home Rd Address: 165 Children's Home Rd
City: Mocksville City: Mocksville
State2ip: NC 27028 State0p: NC 27028
Phone M (336),486-146-8- Phone M (336)486-1468
Property Location&Site Information
Address 165 Children's Home Rd Subdivision: Phase: Lot
Road# Mocksville NC 27028
SINGLE FAMILY Township:
'Structure: Directions
#of Bedrooms: 3 #of People: Hwy 601 North,left Liberty Church Rd.Left on Bear Creek Rd Turn
Left on Duke Whitaker Turn Left at 758 Duke Whitaker Rd.Lot is n the
'Water Supply: N/A right at top of drive Way.
Basement: n Yes❑No Type of Business:
Total sq.Footage: No.Of Employees:
'Proposed improvement:
Replacing MH with double wide
'tisntain
nditions `
i
5 foot setback to any portion of the septic system. 1
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: 2140-Nations,Robert *Date of issue: l a 3 13 x 0 1 4
Authorized State Agent: Z��N Z
**Site Plan/Drawing attached.**
'' „ 41-land Drawing Olmport Drawing
i
Davie County Health Department
�.
1836 Environmental Health Section ;....
a P ID P.O. BOX 848
210 Hospital Street
Date: 2
D Courier#: 09-40-06 Q;1
Mocksville, NC 27028
Phone:(336)-753-6780 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) a lacement Remodeling Reconnection
Name: eem"e_ G'`„vr�[� Phone Numbe>�_33' 7 -/!Z (Home)
Mailing Address:/(,S` CLIJ tr s hon,e_ R.d ✓3�� 5�77-' 2 6 7`j (Work)
Pic 2)0-_' g Email Address: t //c,c azo a l.co.C um
Detailed Directions To Site: 6,OL P, A, 6',6e-ti 0l, rr_ , 4 �71ak ._ je_� ��ke.-. -- C rre�f
kr-m 14./1 dti �u�� (.J�� K-erte Ae �/ rh 1e,/�f' _l-I) /
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Property Address:
Please Fill In The Following Information About The EXISTING Facility: 1AJ h Ri' W H$ aN ?COPe64q)
Name System Installed Under: (i Z 1 Alleo -WType Of Facility: ce _
Date System Installed(Month/DateNcar): Iq q Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? es No If Yes,For How Long? A I knoS-
Any Known Problems? Yes (& If Yes,Explain:
Please Fill In The Following Information About The NEW Facility: (Wha4 (Jou Are p nLi r%3 W i4'k)
Type Of Facility:AQ%,b/e (,J i e, c�u w Number Of Bedrooms:_ Number of People._
Pool Size: Garage Size: Other:
Requested By:'e14&0Date Requested: Z.2 -/2-/y
(Signature)
For Environmental Health Office Use Only
Approved Disapproved
mments: / s✓ !r G�G Q �lGl� - �C
s-
Environmental Health Specialist Dater
*The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee
1
(extendedunited)that the on-site wastewater system will function properly for any given period.of time. . ,
Payment: Cashheck Money Order # Amount:$ (j ,(0 () Date:
. . _
Paid By Received By:
Account#:�Q Invoice#:
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