139 Myers RdDavie County Health Department
OWN
q 18 f ' Environmental Health Section
P.O. Box 848
210 Hospital Street
�.:Courier # : 09-40-06 1911
Mocksville, NC 27028
Phone: (836) - 753 - 6780
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Fax: (336) - 753-1680
Name: UCS eZ 1n n nor Phone Number, (Home)
Mailing Address:�C��+�+'s 1 �u K C'�% (Work)
Email Address:
Detailed Directions To Site: Z,� r lv► �'n / a hLCa
��
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: kvt
N Type Of Facility: _
Number OAedrooms: ,i ;?-Number Of Peopie:� �A P
Date System Installed (Month/Date/Year):p• �l
la 'The_FacilitysuzzentLy� �?-To— ff Yes, For How Long?,
Any Known Problems? Yes No)If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
/" `1-(AV4
L 9%E
Type Of Facility: nU T 1-141 ; A -11^ Number Of Bedrooms: J, l /b 'e Number of People 4 & �
Pool Size: Garage Size: Other: Wd -- -
«--
Requested By: ` & - Date Requested:_
(Signature)
For-
Approved
Comments:
Environmental Health Speciali
For Environmental Health Office Use Only
19atla'iM A A10 se Ac eowmled 16
Date:
*The signing of this form by the 1Cnvirorumental 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
Paid By:_
Account #:
Money Order # Amount:$
Received
Date:
Printed:Jun 17, 2015
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