781 Ratledge Rd ,, .
HEALTH DEPARTMENT RELEASE Foro�iceuseontv
' . . '' *CDP File Number 121785-1
�d�,w�o Davie County Health Department �.s-000-oao��
� ,�, � 210 Hospital Street County ID Number.
,� :� } •� P.O. Box 848 Evaluated For. NEW
'��=�' Mocksville NC 27028
Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID 0 6 / 1 1 / 2 0 1 8
urvri�
Applicant: Steve Gamett Property Owner: Steve Gamett
Address: 781 Ratledge Road Address: 781 Ratledge Road
City: Mocksville C��+: Mocksvilie
State2ip: NC 27028 State2ip: NC 27028
Phone�: �336)492-5298 Phone�: (336)492-5298
Property Loeation&Slta Information
Address�s� �U�9e�d Subdivision: Phase: Lot
Road# Mocksville NC 27028
SINGLE FAMILY Township:
'StrUCtUfe: Directions
#of Bedrooms: #of People: .leriCho Chu�Ch Rd.to Junction Road,Left on Junction 1/2 Mile right on
Ratledge Rd,1.7 Miles log house on left
`Water Supply: WA
Type of Business:
Basement �Yes❑No
Total sq.Footage: No.Of Employees:
'Proposed Improvement:
`R�lease Conditions
It is the responsibitiry 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 bcation of the septic system,please
have a licensed installer or inspector locate ihe septic system for you. The local county health department in no way imp�ies that the
proposed construction meets the required setbacks from the septic system untess otherwise noted. This release o�ly 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 subsurFaoe sewage treatment and disposal
system serving the site will vontinue to function for any period of time.
ApplicantlLegal Reps.Signature Required? QYes �No
ApplicantlLegal Reps.Signature• *Date: � �
*Issued By: ��-oaywait,andrew � *Date of Issue:. 0 6 � 1 1 � 2 0 1 3
Authorized State Agent:
**S ite P IanlDrawing attached.** Total Tfine:(HH:MM)
aHand Drawing almport Drawing 0 1 Ho�� 0 0 Minutes
�' � . _ � �� ���� ��r�
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Davie County Health Department
�0�$Ifi Environmental Health Section ; . _ . ,
� `� P.O. Box 848 ` . �1 `
. .-� �. , �
, � ,��, p� ��� 210 Hospital Street • �
fla�: 5-30_I �;�
O U �'t .� Courier# : 09-40-06 -, �
�+ed s Mocksville, NC 27028
Phone:(336)-753-6780 Fax:(336)-751-8786
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
.Name:_ �� 1 ��� �1"Gr� e�/ Phone Number ���-��Z' �Z`�� (Home)
Mailing Address: G!�� '�l r� �c�j(�O`�i(`{O- '�L`t S (�1�)G�c..C�
. �,Ld-J�G��:sl�( �/p1_��c v� Email S J G�`Id � �/�T�� •/!Ca�
Detailed Directions To Site: v��r L o "�`�- I u V��G`f7d� �C� — �� �� V u,�l��'7�C�--
o lz �'h�l�— v�' (�� oa�. � �'� - �-'7 �h 1f1�s (v t�us� cJ,v Cfi,-�'1�"
Property Address: � / Q Q �P � �..�-�oQ�o'(�/
Please Fill In The Following Information.About The EXISTING Facility: 3�. �20Ac
� f�7� G�a� ,C�; ll ��o
Name System Installed Under: Type Of Facility: ��,5 ]
Date System Installed(Month/Date/Year): /�J 7� . Number Of Bedrooms: � Number Of People:�_
Is The Facility Currently Vacant? Yes No If Yes,For How Long?
An .Known Problems? Yes No If Yes,Explain:
___��1��Ci ��7�H/-c..� •�.���`G�` �D�l?�� .
� Please Fill In The Following Information About The NEW Facility:
Type Of Facility: (,{i'YI /i1/ Number Of Bedrooms: �Number of People
,y(Requested By: ate Requested:�'�=3b -I 3 -
�` ($ignature) ,
� For Environmental Health Office Use Only
Approved Disapproved .
Comments:
Environmental Health Specialist Date:
*The signing of this fortn 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• Cas heck Moriey Order # Amount:$ �-� Date: ` � `�
Paid By: � : ����� Received By: ��
Account#: Invoice#: ��Z
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Ail daU is provided as b without wamnty or puanntee of any kind either axpressed or tmplied tncluding but not limited to the implied �,v.,�
<«� �� warcantles of inerchanhbllity or(Ness for a particular use.All usen of Davie County's GIS website shall hoid hartnleea tho Counly of �h ti�
' Davie,North Caroiina,ks agents,consuif�nts,contraeton or employeas hom any and all claims or causes of action due to or arising out o( P ri nted.Ma 30 2013
S the use or inability to use the GIS data provided by this website. y �