164 James RdHEALTH DEPARTMENT RELEASE
�Y Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Alfred Ray Patton
Address: 761 Bailey Chapel Rd
City: Advance
State2ip: NC 27006
Phone #: (336) 998-2266
PERMIT VAUD 0 6/ a 2/ a 0 1 6
UNTIL
'Property Owner: Alfred Ray Patton
Address: 761 Bailey Chapel Rd
City: Advance
State0p: NC 27006
hone #: (336) 998-2266
Property Location & Site Infonnation
Address 164 James Road Subdivision: Phase: Lot:
Road it Advance NC 27006
SINGLE FAMILY Township:
'Structure: Directions
of Bedrooms: 2 # of People: Hwy 64 East right on Fork Bixby Rd. Go To James Rd. on Left before
Bailey's Chapel
'Water Supply: PUBLIC
Basement: � Yes Q No
"Proposed Improvement:
'Re et ase Conditions
Maintain 5 foot setback from any portion of the septic tank or lines
Type of Business:
Total sq. Footage: No, Of Employees:
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
Authorized State Apeii:
*Date of Issue: 0 6/ a a/ a 0 1 6
**Site Plan/Drawing attached.**
OO Hand Drawing Olmport Drawing
Drawing Type:
HEALTH DEPARTMENT RELEASE
Davie County Health Department
210 Hospital Street
P.O. Box 848
CDP File Number: `219636 -1
County File Number:
Mocksville NC 27028 Date: 0 6/ 2 2/ 2 0 1 6
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Health Depa Release �QNIA
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Davie County Health Department
61� Environmental Health Section
+ t P.O. Box 848
Phone: (336) - 753 - 6780
PAID 210 Hospital Street RECEIVED
Date:T1/10 Courier # : 09-40-06
Receivedby: 1�j,/L,4t&d,( Mocksville, NC 27028 Date: (o to
ON -SIT WATER CERTIFICATION
(Check One) Re lacement Remodeling Reconnection
Fax: (336) - 753-1680
Name: A -1 -eyed 1C_EA�•I �� Phone Number �j7J(���C(A-22(t+(p (Homee.�
Mailing Address: �� 1 33 In r ?Jiff s– (o1 C1 1 -(�h�o )
-Adyo ace. NG 17 0�
Detailed Directions To Site: fL Gh_ 6CtLri-t%M(JYY 7�(.7 L O"A C ry-j0 —y W
Please Fill In The Following Information About The EXISTING Facility: -
Name System Installed Under: , d W00\0 l MQj&&) 1&ciJ Type Of Facility: 1(� Qij(lC:�•
Date System Installed Nonth/Date/Year): U 1'MSt4yt Number Of Bedrooms: 2.OY 3 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: S W M Vj Number Of Bedrooms: 1, of People 2
Pool Size: N ra ize: fj I A Other: .
Requested By: Date Requested: tohh u
Sio atnrPl
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.
Payment: Cash Check Money Order # Amount:$ Date:
Paid By: p 2r Received By:
Account #: � -` co 3� Invoice #:
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All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied warranties of
merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina, its agents,
consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or inability to use the GIS data provided b
this website.
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LN 6;d I Z X &-Ir oNV, 1
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s Printed:Jun 06, 2016
All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied warranties of
merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina, its agents,
consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or inability to use the GIS data provided b
this website.