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884 Wyo Rd HEALTH DEPARTMENT RELEASE ForOfficeUseOnlv ` r� � , .,, � *CDP File Number 124273- 1 ,.�,�,Fo Davie County Health Department �° w•"`..,. B�J-��O-QO-�7-�� ,. � 210 Hospital Street Counry ID Number: � -�:, x �":'- ;� P.O. Box 848 Evaluated For: HDR/V11WC '`���"' Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID � 1 1 1 5 I 2 0 1 8 UNTI L: Applicant: Barry D. Allen Property Ovmer: Barry D. Allen Address: 1773 Angell Road Address: 1773 Angell Road C�h+: Mocksville Cih+: Mocksville StatefLip: NC 27028 State2ip: NC 27028 Phone#: �336) 998-0622 Phane�: (336) 998-0622 Propertv Location&Site Information Address8��o Road Subdivision: Phase: Lot Road# Mocksville NC 27028 SINGLE FAMILY Township: `StrUCtUfe: Direetions #of Bedrooms: 3 #of People: Hwy 601 north tum right on;Hwy 801 pass Dragway,Wyo on the left, goo 2 miles on right in curve,just past Pineville Rd. `Water Supply: PUBLIC Type of Business: Basement: �Yes�No Total sq.Footage: No.Of Employees: `Proposed tmprovement: Replacing Mobile with 2 bedroom home 'Release Conditions 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. �f you are unsure as to the exact location of the septic system,please have a licensed installer or inspector locate ihe septic system for you. The local county health depaAment in no way implies ihat the proposed construction meets ihe required setbacks from the septic system untess 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. ApplicantlLegal Reps.Signature Required? QYes CQNo ApplicantlLegal Reps. Signature: '`Date: � j *Issued By: 2244-Daywalt,Mdrew *Date of Issue:. 1 1 j 1 5 f 2 0 1 3 Authorized State Agent: **5 ite P Ian/Drawing attached.�� Total Time:(HH:MM) 0 1 Hours 3 0 Minutes OHand Drawing Dlmport Drawing , t� ,� . +1 Y � • ` Davie County Health Department ��;s I� .NE� Environmental Health Section � ' �;,: .. , , � ��i CF' P.O. Box 848 Det�, A� � ,,�1 - � � �`` �;��j- 210 Hospital Street �� ``� `/�j , �'m� � ,. .5,, O� ��, ��� Courier# : 09-40-06 -, � Mocksville, NC 27028 Phone:(336)-753-6780 Fax:(336)-751-8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection __-�-- �J � —� l� p Name: �'P' `�� � ����� Phone Number � L�� l 1 8 ��� (Home) MailingAddress: , ��- �y]� (Work) _ ���45 J� //e V �� Email Detaile Directions To Site: l�D/ /V� u�� r% h� a N �� ��/ /�s� .I/�A u� �" Q , Le � � �I s o�� ch� a -f.�� c�c���,� 'as �s � %NQ V%l% • Property Address: (�.1 l. J �Z. -oaa- oo-oa� Please Fill In The Following Information About The EXISTING Facility: � ��D �j� , �� Name System Installed Under: � �,1� �� Type Of Facility: Date System Installed(Month/Date/Year): � �—S�� � Number Of Bedrooms:_,�Number Of People: Is The Facility Currently Vacant? (�.Y� No If Yes,For How Long? � G/����C.S � Any.Known Problems? Yes No If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: �b�� '�`v/r'�� Number Of Bedrooms: Z Number of People � Requested By: � Date Requested: - (Signature) 1 Far 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. Payme t: Cas Check Money Order # Amount:$ Date: ��.�' Paid By: 'l�.����j� Received By: /�� Account#: �QL���� Invoice#: ��� —r ,, ._.. _ .., ,♦: . , � � � g, � F , a � � _ '; � « � : e q, '4 � ,�"�� �'. t?.�p r >. L ��.�1r �' L' �7.� n.`ty` a >✓p_ !� �..`� t'�q��.'a '4��..� :�` I� !Y�� ft�'p'�r '� k��M'�3 � �+y ryp1�5 '. - ."' � 5` '"D�4d0E 'COl�I�TY F�EALgIi- DEPAR�fi�Ef�T.� a � � `� � � . �ro. , : . � ` !. f5 .� :. � •.. � .. '. . . � �_ a� ; .�; ) T��IYI�Ol�tl'�Id1�Gl�tl��7. ����IYII� iil\7��'.����'r�JC�4,�E O�� CO.,f�PLETBO.� ar'`t ,.• y�d..;. i y xi� t'C,y��''��� �� � �9 .- a.-� re._.y '� .w� +'�. t ':' , < ¢" -.. :. �S �;� . i ��; *Note�sued in Compliance with G S ;of Nor,th Carolina Chapter�130 FArticle 13c � � ;� }= - � � � - � ��� � ' �: �� ,� � � � �.,� ��Per�aq4�� fi�uanber� �a� � � �-��.� � ���, ;�� �> � , �.;- �, �"� �; � � + �. � � '�,r �w/ a� Y� � 4+: �'= �`r � II � z t 7 y : ,Narne= ,;�`� �� .��r``E`'�� .�. � Date*-� �'�'�`� �''.f'' .�.� � � `� ��1� ��t:.�� � ' rh� �, ,v` b �• � i') �A".� . {'� _ .. D�m . . . ... . . _ ." 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' ,� � � 3 a � � SubdiVision Name � ° �' �,Lot No. Sec or;Block No '`� � � � . � .k'� S .j "Y Y `k��i �. � .� `k ,U '_ � 3,�, � �i P - 3� �.'� n ,' S k �� � h ,, t �=Lot Size ~�� �1���� ° � House ° +- Mokiile Home _`r��-_ Business -- '� Speculation - tT �: . . . h f, d4i� � °. n -$ �..�,� �3 H� � l .. ��� . 4 .T - 3� °y j �4 .'. } .r.. ,• �. _ T � 7 �' ' �No :B"edrooms �� `�:No Baths� x ����No .in Family � «�"`� '� � �w'�� � ' � ��' ... � . . - � . . . . _ _ . k ,= � �,. _ ,' -` p, J� S � � :�Garbage Disposal YES ❑;. NO � ; _� "hSpecifications for System .p }�,� � � ���`��� �� � i: �� x a� `�''.� ` ��.r+�.� �`r w ��� t ��.:� a. ?e ,�,��.,, =Auto Dish UVasher _ YES ❑�. yN0 � � ,,,��:�,�',d'` ,'�,t�� - , { Auto<V1/ash Machme YES 0'� NO ;� ,� = � � /'{r7/�' ' � L 3.�. -.Qk 4 ;� �m,t �. �� + k,;r -..����^��J�,s� �� ` � 'r� � '��f� 2:;� �{sr.�i o s ���� r �k' '�. i.'. H. x �.;� ��s i�.' '�'� i....-°:'� � ' e. �e 4 � Type`Water�Supply -- _ � , ; '! � ' � � . 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Department for final inspection of this system between 8 30 � ��, 9 30y A M �or 1 00 1 30 P M on day of completion Telephone Number 704,.634 5985 G•� ' � � ,� t1. �,r� �, �� �;_, .�, � �se -g.rn -� ;�& i,'+: +:�,'� r i`� ;�' �^ (r rr��s � e � '� -.s ' . w .. ,� .,3 � - � _` : f l / " S ` �` ,� d�,�Final�:lnstallation'D,iagram�: �t � � '�� ` � ��` ���,System Installed by� �������-���'�f'!� � �� �� h,� .r a:�, "' :� � a+ `� �... :�'Y a� t,ar q A., . _ . ^� ,!� . /. { � ,r� C� �,-a�: 's; . f�• t'�. 'Sr- � »p , r ��i.: ,(!�,-�'.' .. - ��•: . .-6 `� , '"if° � . ' �: 5s=. µf � - 9 r ) F,., r � . . � : _f �, r=•• 'i /f�'. t a ,.H ,�. �9 n" ' s .:s'� / :i •! ( I / '_ � w fi;� JS ;�',� ,�:.- d 't .z�+ LK°"'�w r ��` , 4'' (�,..' ����/�� � °N ��u. 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'!'.-r'����s i�' � . . , ^� � °* �� ; , :� ' �� , �:,� r ,� r ertificatewofCompletion, � �� �-Date$-� � ;; � .. � � C , ,. � _� � _ , �` fr. � �The signing of.this ce�rtificate�shall indicate=that the,system described;�above�,has been ins','talled-i�n compliance. with - � '�the`standartls set:forth m the abo�eRre � � ` `� ""� ��� .. � „ gulation but+;:shall m'NO way be taken as�a guarantee th�at theKsystem:will function� � �L� 4 • satisfactoriiy for any given period of time � � , _• : ;� �, _ �. . !`._ �.. .� ._. ....4a. .. .�..�.,�7. . �.u. ,.,..�.� , .:�.5' ., . , e . ..,�r..4„ i�,...,. ., a ., +a� a._ .. . ....��.f 7 _, . ,.m�� J r, _..� . �t.. v, Aae:'�.�.e�.Siz.�";�F���. � ' ' ` DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'Note:'l�sued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name /v1 �� �` ���- Date Location _ l/V /�flt'- Subdivision Name Lot No. _ Sec. or Block No. Lot Size House Mobile Home _ Business __ Speculation No. Bedrooms � No. Baths — � No. in Family _. Garbage Disposal YES p NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO p Auto Wash Machine YES � NO ❑ Type Water Supply __ *This permit Void if sewage system described below is not installed within 36 months from date of issue. improvements permit by -- ' *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by � � ;r ,-' I Certificate of Completion Date — #The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. � DAVIL COUi�?TY HEALTH Ds?PAP.^t.IEi?T '� EI1VI�;OY1i r.i�TTAL �ALTH SECTIOrI �OIL/SITr� EVALUATIOt? T?AI� �•,l) A Ile� DATE `"j���s��� ADDRESS �b E I.ME R- G..�GE '�.-�•�1� �►�l 2�0 �uc,M'. LUCAiI0i1 '�,h�u,l)e R� - �p ^�v �nc9 -�• R-�'• a�QaP 2�. , . 2 w:.�t n rcr�a� C 4 r v t,. rr�ae cr,.�p e c. :1•�s� �ia.Fwe. t�1�2 hw�t c, LOT SIZ� q.�Q,/��, l� A�.[.m.t3 TOPOGRAPHY< S` SOIL 2E.�TUFtE s I�J , e : 50IL STRUC�URs�.o L�• ,� D�PTE a / _ �� // C� TZESTRICTI�TL HGF.IZOT?S o j���� �� � �e PERCOLATIOPI F.�1TE e Presoal,. 2iark & tine Dro Time F.ate iiit:. Tnch 1. � �� r.� 2. /1 " �-- �'�` �. � " -- I °�%��'�CLASSIFICATIOY?�Suitable Provisionally Suitable Unsuitable COF�:�ITTS e � Pe...v. _�M•!�• _.�„�,Za =�• �v�,a.e�..�'`�+.. - � p�•�P4-- SAI�?ITARIATT SIT� DIAuEt�`i