4310 Hwy 801S (3)HEALTH DEPARTMENT RELEASE
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: William Ratliff
Address: 190 NC Hwy 801 S
City: Woodleaf
State2ip: NC
Phone #: (336) 624.6351
For Office Use Only
*CDP File Number 197665-1
V-000-00=103-03
County ID Number:
Evaluated For HDR/WWC
PERMIT VAUD 1 0/ a 0/ a 0 2 j 0
I I AITI I
rproperty Owner: William Ratliff
Address: 190 NC Hwy 801 S
City: Woodleaf
State2ip: NC
Phone #: (336) 624-6351
Property Location & She Information
(A�ddress4310 NC Hwy 801 S Subdivision: Phase: Lot
Road #Advance, _ _ NC 27006 _
SINGLE FAMILY Township:
'Structure: Directions
of Bedrooms: 3 # of People: Hwy 64 east right on Hwy 801 2nd drive to right, back off road
'Water Supply: N/A
Basement: F] Yes ❑ No Type of Business:
Total sq. Footage: No. Of Employees:
'Proposed Improvement:
Replace Home
Maintain 5 foot setback to any portion of the septic system
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.
ApplicantlLegal Reps. Signature Required? QYes ONo
Applicant/Legal Reps. Signature', 'Date:
*Issued By: 2140 -Nations, Robert *Date of Issue: 1 6 I a 0 a 0 1 5
Authorized State Agent:
**Site Plan/Drawing attached.**
' fir: ®Hand Drawing OlmportDrawing;
Drawing Typl:
HEALTH DEPARTMENT RELEASE
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Health Department Release
CDP File Number: 197665 -1
County File Number: J7-000-00.103-03
Date: 10/20/,2015
0Inch
Scale: Q Block
Q N/A
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Davie County Health Department
�is f pEnvironmental Health Section pA
P.O. Box 848 I%Atli –3-(
— I
210 Hospital Street Tj _vJ
Courier # : 09-40-06 1
Mocksville, NC 27028
Phone: (336) - 753 - 6780
ON-SITE WASnWATER CERTIFICATION
(Check One eplacement Remodeling Reconnection
Name: (V 1 !� r'G-ti'►'1 �G� u,1 Phone Number ,jl(p -&a 7' 3 5'/_(Home)
Mailing Address: /CID C�l (Work)
�CrCl (Cal (A) C Email Address!� 4-c� v.< wci ; / • ccw
Fax: (336) - 753-1680
Detailed Directions To
Property Address: �% %() / ' ( S, ,J - � 3
Please Fill In The Following Information About The EXISTING Facility: 6/03 A
Name System Installed Under: ll )CY Y► G V1 &Ckhpf- Type Of Facility: �1-51J'(A c I
Date System Installed (Month/Date/Year): 4F Number Of Bedrooms:_3_Number Of People:
Is The Facility Currently Vacant? G 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: arage Size: P JA- Other: /N'[A
Requested By: Date Requested:/0/) 3� i
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 or limited) that the on-site wastewater system will function properly for any given period of time.
Check Money Order #
Amount:$
Paid By: r Received By:
Account #: Lo, lis 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.
dl✓ �t01j,t%fSotJ Date �- , r Permit Number
Name1 7 • 76
W
ro .o / Gv
Subdivision Name Lot No, Sec. or Block No.
/�
Lot Size ❑ G•' House • Mobile Home L"OfBuslness Speculation.
37
No. Bedrooms No. Baths No. In Family
Garbage Disposal YES ( NO Y, Specifications for System: ad !L
Auto Dish Washer YES 2 NO 0 / / /!
Auto wash Machine Y[:NO ❑ X 3 X /'Z 67 _01-1 e -
Type Water Supply–
'This
upply_'This permit Void if sewage system described below is not installed within 36 months from date of Issue.
Ole
i
`+
1 � 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 7:00-1:30 P.M. on day of completion. Telephone Number: 704-634--5985.
Final Installation Diagram: System Installed byt11Ab VFt�?
w—fl6s ���
L)uE Tu P&T
Certificate of Completion •' ` ' Date
-3
`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 taker. as a guarantee that the system will function
satisfactorily for any given period of time.
s