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1048 Country Ln
Davie County Health Department V t� Environmental Health Section P.P. Box 848 L 210 Hospital Street m 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 Name: /D �_Aj_ S'J ' Phone Number �3�P Z5/ (o Q (Home) Mailing Address: 4 3 /q A /_ `/11 0I� (Work) 5 //�L� CEmail Detailed Directions To Site:T( ()�1.58 jar,-r (S E-r © N 06U tl 4_U_L.ah ffa_ Aa Property Address: Please F�I(n,/The Following Information.Ab out The EXISTING Facili ,1 t Nam(ystem hist talled Under: -S ype Of Faolility: / (. Date System Installed(Month/Date/Year): Number Of Bedrooms.3 Number Of People: Is The Facility Currently Vacant- No If Yes,For How Long? S. Any.Known Problems? Yes If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: Number Of Bedrooms: Number of Peoplek. _ Requested By: Date Requested: (Signature) For Environmental Health Office Use Only Approved Disapproved Comments: a 04 117 Z Environmental Health Specialist Date: IL �•L y *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 checkMoneyOrder # / Amount:$ NI,(10 Date: Z Paid By: (� �, �/ Received By: •,US Account#: /r�U["L�� Invoice#: ffO 7 7 "f120 i(79 . l i191m ((}�ryry a *i 991 ilio' i 4 w. a� J "yz 309 All data is provided as is without warranty or guarantee of any kind either expressed or implied Including but not limited to the Implied n warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the County of U N Davie,North Carolina,its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out Printed:Mar 25, 2014 5 of the use or inability to use the GIS data provided by this website.