368 Howardtown Rd Davie County Health Department
18 r Environmental Health Section j ;,....
a. P.O. Box 848 a.
_3 210 Hospital Street
C'�.. AA-. .!
0 Courier# : 09-40-06 '4 Q
Mocksville,NC 27028 r
Phone:(336)-753-6780 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: Illqs Phone Number �7 Ono , (Home)
Mailing Address: (� �(�( otvo (Work)
�Ck5✓i I Email Address:
Detailed Directions To Site:
Property Address•��ra y J—a r d W lJ
Please Fill In The Following Ilnfformation About The EXISTING Facility:
Name System Installed Under: /"/ . �C Gr l Type Of Facility:
Date System Installed(Month/Date/Year): 9 � Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes No If Yes,For How Long?
Any Known Problems? Yes No If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: Number Of Bedrooms: Number of People
Pool Size: ge Size: 20 X yk • Other:
Requested By: Date Requested: 4�
(Signature)
For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist Date: I
*The signing of this form by the Environmental Health Staff is in no way intended,nor should be takeri 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 # Amount:$ Date:
Paid By: Received By:
Account#: Invoice#:
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name Date
Location
Subdivision Name Lot No. Sec.or Block No.
Lot Size t C House Mobile Home— Business Speculation
No. Bedrooms No. Baths I No. in Family
Garbage Disposal YES C❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO p
Auto Wash Machine YES ❑ NO CI �jTT�0 3 x N2 5 rely L
Type Water Supply - 0x O �Co&w efe
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
i
� 1
y
i
Improvements permit by -
'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number:704-634-5985.
• Final Installation Diagram: System Installed by
r'
ALL
`i L
ti
Certificate of Completion Dat�l
'The signing of this certificate shall indicate that the system describ6d above has been installed in compliance with
the standards set forth'in the above regulation,but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
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HEALTH DEPARTMENT RELEASE For Office Use Only
*CDP File Number 122096- 1
SrNro Davie County Health Department
��' G6-000-00-058-02
�yyn 210 Hospital Street
County ID Number:
p
_ P.O. Box 848 Evaluated For: HDR/VVWC
Mocksville NC 27028
ne: 0 Fax: 336-753-1680 PERMIT VALID 0 7 / 0 5 / 2 0 1 8
UNTIL:
Applic t: Herbert Reich Property Owner: Herbert Reich
Addres t368Howardtown Road Address: 368 Howardtown Road
City: Moc s ille City: Mocksville
State/Zip: NC 27028 State0p: NC 27028
Phone#: (336) 998-2910 Phone#: (336) 998-2910
Property Location&Site Information
A dress Road Subdivision: Phase: Lot
R d# 27028
FAMILY Township:
'Structure: Directions
#of Bedrooms: 2 #of People: 1 Hwy 158 to Howardtown Circle on right turn there and follow to
Howardtown Rd.On right
'Water Supply: NIA
Type of Business: Replace Mobile Home
Basement: F]Yes F]No
Total sq.Footage: No.Of Employees:
*Proposed Improvement:
Replace Mobile Home
(-*Release Conditions
1It 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 dispose
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: 0 7 0 5 2 0 1 3
Authorized State Agent:^
**Site Plan/Drawing attached.* Total Time:(HH:MM)
0 1 Hours 0 0 Minutes
G Hand Drawinq OlmDort Drawing
Davie County Health Department ru\ct 4o
4[s j� Environmental Health Section
P.O.Box 848
210 Hospital Street '
D �'S Courier# :09-40-06 ('
Mocksville,NC 27028
v
Phone:(336)-753-67 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) eplacement Remodeling Reconnection
Name: �-1� Q� �Q.�C.h Phone Number 33 Le d (Home)
Mailing Address:_&Ds ' C� UJB (Work)
M t�5LKSk�i�I2 /V C- Email Address:
Detailed Directions To Site: (LK Q P W Q 151B EQSk +L'y V) R i a h 4 b V-\ 17. V--1. m i te-S
- L,'tv) Le_V-1 car, 0r)W .Vrd40Vz:1k_\C;rc12 a6 3114 m; I-e -I-t,_v'n r iG to - en 1AMOWA4cwn 1631 4 enc Ie-
i b tea- i L�=1
Property Address: � A W n rn bj
-Dp6-pp-p - Z
Please Fill In The Following 'Information
About The EXISTING Facility: l
Name System Installed Under: Aflksh 1 N lies Type Of Facility: M()bi`-e 4b v'W-2
Date System Installed(Month/Date/Year): 9$L) Number Of Bedrooms:__Z— Number Of People:-
Is
eople:Is The Facility Currently Vacant? Yes (9) If Yes,For How Long?
Any Known Problems? Yes (8 If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: m DID; 0 �U TQ- Number Of Bedrooms: c>� Number of People_
Pool Size: Garage Size: ` Other:
equested By. , �- Date Requested:
(Signature)
For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee
(exte or 1• ited)that the on-site wastewater system will function properly for any given period of time.
Payme t: Cas �,,�ijeck Money Order # Amount:$ Date: i`3
Paid By: f�L-t Received By.
Account#: 2Z Invoice#:
No Floor P1a'j
���� ������ HEALTH DEPARTMENT
~~ , -
~ IMPROVEMENTS PERMIT A�D CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.G. of North Carolina Chapter 130—Article 13o.
^
Permit- Number
Name Date
`
Location
--
Subdivision Nome Lot No. Soo. or Block No.
Lot Size Houoo __-_-_--_ K8obi|e Home -_-�L��_ Buuinouu -_-___-_ Speculation
~_
No. Bedrooms No. Baths __ I�___-_ No. in Family '2,
Garbage Disposal YES �� NO �� Specifications for System:
Auto Dish Washer YES NO
,
Auto Wash Machine YES [] NO rertj
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
-
Improvements permit bv
*Contact o representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00'1:30 P.M. on day of completion. Telephone Number: 704'834-5985.
Fina| Installation Diagram: Svnhsm Installed
�
^ ^�.
tion -If DaW
` ^
*The signing of this certificate ehe|| indicate that the system d000r has been installed in compliance with
the standards set forth in the above regu|atiun, but shall in NOway botaken as aguarantee that the system will function
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE
NAVE ,
LOCATION
FINDINGS: HOLE NO. C01,24ENTS
4.
S.
6.
Ey:
LOT DIAGRAM
1
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f
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTIOtd
P. 0. BOX 57 I 1
MOCKSVILLE, N.C. 27028 :
(704) 634-5985
Statement for Septic Tank Improvements Permits and/or Site Evaluations
NAME T . �.- i 1 Aya sm b w Y-S DATE ' r
ADDRESS_ rZ-�.
PERMIT I�(0. Z��"�
_lh2c a VI t,1.4- G Z'7 028`
EXPLANATION OF CHARGE :S111 G Ulf I-VAIZ41 "'
AMOU41ur, SANITARIAN .�
PLEASE REMIT THE ABOVE A14OUNT ON RECEIPT OF THIS STATEMENT. '
*NOTICE: Evaluation(s) can not be completed until paynent is received.
Improvements Permit(s) can not be issued until payment is received.
• DAVIE COUNTY HEALTH DEPARTMENT
,1 .E IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued iri Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name Date
Location m
Subdivision Name Lot No. _ / Sec. or Block No.
Lot Size House Mobile Home— Business Speculation
No. Bedrooms �' No. Baths �` No. in Family�l�
Garbage Disposal YES ❑ NO.14Specifications for System: 'goo! gGL
Auto Dish Washer YES ❑ NOU
Auto Wash Machine YES ❑!. NO `j 0'd' 3' x LZ S reQ
Type Water Supply ,Dr boX 0,r j` ,cow& . o
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
f
\,J
Improvements
a
t ,
ri a
,.S
e
k
fl_
Improvements permit by—,--*'-'
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number:704-634-5985.
Final Installation Diagram: System Installed by! -f �+ � l�t�
t�{
Certificate of Completion ' r' Dat !
*The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation,but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.