333 McKnight RdHEALTH_ DEPARTMENT RELEASE
dA Davie County Health Department
tr 210 Hospital Street
- P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: June M.13Uzzard
Address: 333 McKnight Road
City: Advance
StatefZip: NC 27006
Phone ;M: (336) 998-4367
For Office Use Only
*CDP File Number 122783 1
bs-000-00-024
County ID Number:
Evaluated Far. HDR/V1IWC
PERMIT VALID 0 8/ 1 5/ 2 0 1 8
UNTIL:
r
roperty Owner: June M.Ouzzard
ddress: 333 McKnight Road
ity: Advance
State0p: NC 27006
Phone M (336) 998-4367
Property Location & Site Information
Address 333 McKnight Road Subdivision: Phase: Lot
Road # Advance NC 27006
SINGLE FAMILY Township:
*Structure: Directions
# of Bedrooms: 3 # of People: 2 1-40 to 801 North, approx 3.0 miles to McKnight road tum right and
proceed to end.
'Water Supply: N/A
Type of Business:
Basement: � Yes ❑ No
` Total sq. Footage: No. Of Employees:
'Proposed Improvement:
Detached Garage
It is the responsibility of the owner to maintain a 5 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 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;
*Issued By: 2244 - Daywalt,
Authorized State Agent:_
*Date:
*Date of Issue: 0 8/ 1 5/ 2 0 1 3
**Site P IadDrawing attached.** Total Tlme:(HH:MM)
0 Hand Drawing Olmport Drawing 0 1 Hours 0 O Minutes
Phone: (336) - 753 - 6780
NO AFW i-� DuN4�
Davie County Health Department
Environmental Health S *6 '
P.O. Box 848 C� j Uj%' 1
Y� 210 Hospital Stree
(3 Courier # : 09-40- 6
Mocksville, NC 27 28
•�,T`S Fax: (336) - 753-1680
ON-SITE WASTEWATER CERTIF
(Check One) Replacement Remodeling Reconnection
Name: Xo N 41 0 Pf & Phone Number (Home)
j
Mailing Address: C .. "� D 1 "f ' _(Work)
L) et Av C.e_M? DD ,�,
Detailed Directions To Site: .Z
Property
Please Fill In The Following Information About The EXISTING Facility:
1%,06
Name System Installed Under: /Y%% , k Type Of Facility:
Date System Installed (Month/Date/Year): 19� Number Of Bedrooms: Number Of People:_
Is The Facility Currently Vacant? Yes 0
If Yes, For How Long?
Any Known Problems? Yes (20)If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: iLC,44 �ar(_!�; Number Of Bedrooms:
- -
Number of People
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.
Paymen : Cash Check Money Order # Amount:$ 0" Date: j - I q
Paid By:Received By
IIrr rr Q
Account #:� f , Invoice #: S &5�
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