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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 r-dCJC L U1 4 r 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