2448 Milling RdHEALTH DEPARTMENT RELEASE
d,.sr,o Davie County Health Department
210 Hospital Street
a ` P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Covenant Buliding Company LLC
Address: 1010 Will Black Rd
City: Salisbury
State2ip: NC 28147
Phone #: (704) 798-0815
For Office Use Only
*CDP File Number 219376 - 1
County ID Number:
valuated For: NEW
PERMIT VALID 0 6/ 0 9/ a 0 a 1
UNTIL:
Property Owner: Melinda Norman
Address: 2448 Milling Rd
City: Mocksville
State2ip: NC 27028
Phone #:
Property Location & Site Information
Address2448 Milling Road Subdivision:
Road # Mocksville NC 27028
Township:
Directions
Hwy 158, right on Milling Rd. 4 to 5 miles on right
*Structure: SINGLE FAMILY
# of Bedrooms:
'Water Supply: NIA
Basement: F-1 Yes Q No
'Proposed Improvement:
Storage Building 24x24
# of People:
Phase: Lot:
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 *Date of Issue: 0 6/ 0 9/.1 0 1 6
Authorized State Agent:
**Site Plan/Drawing attached.**
G Hand Drawing Olmport Drawing
Drawing Type:
IER
HEALTH DEPARTMENT RELEASE
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Health Department Release
3 f
•
CDP File Number: 219376 - 1
County File Number:
Date: 06 / 0 9/ a 0 1 6
0Inch
Scale: 0 Block
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Phone: (336) - 753 - 6780
Davie County Health Department
Environmental Health Section
P.O. Box 848
210 Hospital Street
Courier # : 09-40-06
Mocksville, NC 27028
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Fax: (336) - 753-1680
Name: G Phone Number 70 y—i5'.�?- OPl f--' (Home)
Mailing Address: p o 1 / a&cmSrf' (Work)
Sr�l3 Lfl;L .. /UC' g f/ X7
Detailed Directions To Site: 60 1wtis X -ark -I
%—ol !P/ACC
Property Address: a Xeg L92, -//,v„ ,f &2Q y1'*& Ale a7.6.,2g
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: / �� t1 �ZU L' /I r -S Type Of Facility: T✓ ��C S�j
Date System Installed (Month/Date/Year): Iq 5q—N Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes No If Yes, For How Long?
Any Known Problems? YesNo f Yes, Explain:
Please Fill In The Following Informs ion About The NEW Facility:
Type Of Facility: 96 fGt 9e � 161d;�9 aVX'RV Number Of Bedrooms: —1�9— Number of People
Pool Size: Other:
Requested By: Date Requested: .�
gnature)
For Environmental Health Office Use Only
Approved Disapproved
r i
--�G��i��//�7
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 oKlimited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash (Che Money Order #
Amount:$
Paid By: Received By:_
Account #: l -4 M(p Invoice #:
Date:
RV+I--I
c�
S Printed:May 23, 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.