120 Shutt Rdr
Davie County Health Department
4�16I Environmental Health Section
-•a" P.O. Box 848 gl , l
t? '�`,210 Hospital Street
Q LIQ Courier # : 09-40-06
Mocksville, NC 27028 {!
Phone: (336) - 753 - 6730 Fax: (336) - 753-1650
ON-SITEWASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name:,Do� /!�'� Phone Numb(Home)
Mailing Address: fw-es' ��tl /moi % (Work)
Detailed Directions To
Property Address:
Please Fill In The Following Information About The EXISTTVG Facility:
Name System Installed Under: DO-- Q Type Of Facility:
Date System Installed (Month./Date/Year):
Number Of Bedrooms: `� 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: L7N Number Of Bedrooms: Number of People
Pool Size: Garage Size: Other:
Requested By: Date Requested:
(Signature)
Comments:
For Environmental Health Office Use Only
Environmental Health Specialist
d�
— 36
*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:$
Paid By: Received By:
Account #: Invoice #:
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August 22, 2016
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Sources: Esri, HERF_ Delorrno. USGS, Intff ep, inrsemert P Corp.,
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Mapmylndia, 0OPerGtmetWpcontributors, and the GIS User Cornmruty
Davie Courcy GIS
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Davie County Health Department
RECETU'Do mental Health Section
Dial -i'1.0. 3ic�
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`° 3�-- ---- ILIlospi(al Street.
Courier #: 09-40.0 i
1lockm ille, NC 27M
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replaceuxent Rexxxodeling Reconnection
Fax: V336) -- 7,13-1080
Name: Toup1 kcLs PE`tJl – PhoneNumbcr 33U=9 -:21---12531e – mome)
Mail l4lAddress:_]Q`j� (Work)
Detailed Directions To Site: Q41- 8 o J �V"S --}s;'t-nn � tl L:)/"�X
Property Address:�t�{y`�
Please kill in The Following information About The FX[STING Facility:
Name System Installed Utider:_bz:. -G � , 0 L Type Of Facility:
Date Sysi.cm Installed (Month/Date/Year):(, � \Number Of Bedrooms:^Number Of People:
Is The 1~acility Currently Vacant'? Yes No If Ycs, For How Long?
Any Known Problems? Yes No If Yes, Explain:
Please Fill In The Following lfnfor at' o/n� About The:�adlity:
Type OfFacility; L Number Of Bedrooms: Number of People
Pool Size: Garage Size:_ Olhcr;
Requested By: Sm.:4,- Date Requested: _
(Sire
For Environmental Health Office Use Only
pproved isapproved
Comm
Environmental ,Health Specialist Date: l 3 0)- —/G
*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. I
Payment: Cash Check Money Order # Amount•.s /(MM Date:
Paid By: Received By:
.Account ILI O —1 V Invoice #:
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(3.41A)
8006
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144
7793
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(3.57A)
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(4-35A)
• A HEALTH DEPARTMENT RELEAS
�aµpSTNEo
Davie County Health Department
t 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Douglas Spry
Address: 120 Shuott Rd
City: Advance
State/Zip: NC
Phone #: (336) 971-2536
Addre644
Road # Advance NC 27028
`Structure: SINGLE FAMILY
# of Bedrooms: # of People:
*water Supply: N/A
Basement: F] Yes ❑ No
*Proposed Improvement:
deck
27006
For Office Use Only
*CDP File Number 140076 -1
County ID Number.
Evaluated For: HDR/WWC
PERMIT VALID 0 7/ 3 0 1 a 0 1 9
UNTIL:
%Property Owner. Douglas Spry
Address: 120 Shu6t Rd
City: Advance
State/Zip: NC
'\h one #: (336) 971-2536
27006
Property Location & Site Information
Subdivision: Phase: Lot:
Township:
Directions
Hwy 64 E. left on Hwy 801 toward Advance, Pass Ellis Middle School
Shut Rd on right
Type of Business:
Total sq. Footage:
Proposed deck goes back in place of current foot print. Meets current setbacks
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? O Yes O No
Applicant/Legal Reps. Signature: *Date:
*Issued By: 2140 - Nations, Robert *Date of Issue:_ 0 7 / 3 0 / a 0 1 4
Authorized State Agent:
**Site Plan/Drawing attached.**
® Hand Drawing 0 Import Drawing
Characters
Remaining
672
4
Drawing Type:
HEALTH DEPARTMENT RELEASE
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Health Department Release
Page 2 of 2
CDP File Number: 140076 - 1
County File Number:
Date: 07 /30/.1014
O Inch
Scale: O Block '-ft.
O N/A