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230 Staya Way _ _ �' For Office Use'Onlv " _ • HEALTH DEPARTMENT RELEASE , _ _ _ *CDP''File Number "�95782-1 �d��►,�.6� Davie County Health Department � �, 210 Hospital Street Gounty ID Number. . � P.o. Box 848; !HDRNVWC �.4��. Evaluated For: Mocksville NC 27028 . ._ _ _._ Phone: 336-753-6780 Fax:336-753•1680 PERMiTVAu� � g / 1 8 / a 0 a 0 UNtll: Applicant: Kim Stanberry Property Owner. Kim Stanberry Address: 230 Staya Way Address: 230 Staya Way City: Mocksville ���Y� Mocksville State2ip: NC 2702$ State2ip: NG 27028 Phone#; (336) 971-9277 __ _ _ _ Phone#: (336)971-9277 Prop�rtv Locatfon 8 Stte Information Address230 Staya Way Subdivision: Phase: Lot _ Road# M�vilie NC 27028 OTHER Township: 'Strutture: otrections #of Bedrooms: � #of People: � Hv►ry 1581eft on Farmington Rd.cross Hwy 801 Right on Hube�t,left on _ _ . Staya Way _ _ _ 'Water Supply: �A Type ot Business; Work Shop/Studio . Basement:, �Yes o No Total sq. Footage: No.Of Empioyees: � •P�o�osed Improvament: " Work shoplStudio 'R�leas�Conditlons i Maintain 5 foot setback to any portion of the septic system I This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system setving the site will continue fo function for any period of time. App(icanUlegal Reps.Signature Requir�d? OYes flNo ApplicantlLegal Reps.Signature• 'Date: � � *Issued By: 2�40-Nations,Robert 'Date of Issue: � $ � 1 8 � a 0 1 5 Authorized State Agent: � : **Site P IanlDrawing attached.** �� � ;"�.��"°'�� � �Hand Drawing 4lmport Drawing � HEALTH DEPARTMENT REI.EASE � " �s�a Davie County Health Departrnent CDP File Number: �9�782 ' 1 �d ��� �, 210 Hospital Street � P.o.�ox sas County File Number. ' Mocksvilie Nc 2�ozs Date: ,�.s.l.1,8,/ a.0_�.5 �.,��.,.o�,µ � °`""` �Inch Scale: . OBiack = .ft. Draw;ng Type: Health Department Release � � � ON/A � � � . �._,. �...._._:_....._._ ..,.,�.,..�..._,.�.,. ._,�,T..,.. � 3 ____. i w.. —____ .m._ _�.,_, ' .._..��__.:�.. �..�..� �' � __..__�i.�.! ___.___ � � _.. _____�_ , -� ...---� ; � � � ��, G � � � f � � : � ,� --��ti,/�-�. �— ------ —,n ----- , — , u,�J`' � ��S � � _ __..... i __..; � � �.__._i_ ` � r �—�- � , , - � - - I�� � � 4 Q��`- � � � � � y � — _ _�- � r___._-� .,�.�_ � �� t � � . � � � r �� _ _ -( _ _� _w �--�.---�� �.. __ _� �k� � � �� � � � f � �� � �� �� � �,�•�� I �� � � _ _ : � �� . _ � � - __.._ ��___.. �� � ��� � �� �. � �� 1--� � � � � �� � �� : _�� , ._., o�'`: � ._._�__.� -�, �� :�- �-� �..-__j . •� � �� �� °� _i�...�: f � _� .. ._ . . _� , _� �' ..�.:� __._,.�y� .i�}_ _ _._ w � �... .� _ b��'�-'� ..____. � � �� �� � c ,,,,1.., � • � �� � � . ..r�. �.. �.....�..:...��....: . �. :.i��.."... . . . . � . . .I.. � _ . � � ' . . _.. � ...r � _ �I � . ... .,� .. --#. � � . � __.. . . .. . .� _.� .;;� �� :� �� � I �� � � __ /�,,�i �o•� � __c�,.�. ��,���.....I,� ._._.�.�._. .�..�,(�� / � � � _ ._ .,,,,..� � � ' � _ � _ : � _ � � -_____-a. � _ y___..� � "__._._�. I I � I _�Page 2 of-2 . �` •, a ... -- . KS,���� � �a� I��or� ..:. �'f � Davie County Health Departrnent �4�i�ft� Environmental Health Section ��,r,�_yi , � P.O.Box 848 ' � 210 Hospital Street ` ' �'' � O U�'t Courier#:09-40-OG •, Mocksville,NC 27028 , Phone:(336)-753-6780 Fax:(336)-7531680 ON-SITE WASTEWATE CATION (Check One) Replacement emodeling Reconnection Name: 1 Phone Number,33�o �f 7/ �o� 7'� �H�e) Mailing Address: s (Work) mo���vc.�.��... N� �D a fj Detailed Directions To Site: . n � pF, — h��e. o PropertyAddress'_ �3( CZ Q;tA /YIc.C_J'�$V�..�..LQ, �C— G�7ao�� Please Fill In The Following Information About The EXISTING Facility: ' Name System Installed Under:Ul1/�110� /1 n �it �� QIIa��Q„__Type Of Facility: ��l�l�i Date System Installed(Month/Date/Year): (�11{{I1�U.7n /� Number Of Bedrooms: � Number Of People:O( Is The Facility Currently Vacant? Yes No If Yes,For How Long? Any Knovm Problems7 Yes Qo If Yes,Explain: Please Fill In The Following Information About The NEW Facility: �n ����� �N �p, � ���i� Type Of Faciliry: � � umber Of Bedrooms:�Number of People�_ ;� Pool Size: Gazage Size: Other: S� Requested By: Date Requested_���'� � ( ignature For Environmental Health O�ce Use Only Appr ed Disapproved � , "` � � �/ � Comments: Q /G� �� , y� • � Environmental Health Specialist - Date:_ �� —/ 7'—�� � *The signing of this form by the Environmental Health Staff is in no way in en e ,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of tim_� Payment: Cash hec Money Order # Amount:$ Date: � Paid By: Received By: Account#: Invoice#: � = - . 9 , ,` � ���� S �� � ��'�'Q,,.�-- c�.�d- � W`� '� � ��� �� � � �� , �, _--- - I�QK�