477 Underpass Rd Davie County Health Departrnent
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Y �q�is f� Environmental Health Section '� „ _ �° ;
� ` , P.O. Box 848 � " `� •
�} �`,a,r 210 Hospital Street `� ��r��,°.' �
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p U,�'t �A � Courier# : 09-40-06
� �ti3 Mocksville,NC 27028 �Y
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Phone:(336)-753-G780 1 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: S Phone Number -I�9" o���v 1 �,Ce�(�erHe}
Mailing Address�3a 5 . ��S!J l,� � '1 �� - �S�JSo (Work)
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Detailed Directions To Site: 2�O �. �}-O eX.� -}- I � . ��"1'1 C3�'� }�l,e��,r �o� -}-� 1°,d ti�ncv
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Property Address: 1 C� Gefl ` /v�. �] O T�
Please Fill In The Following Information About The EXISTING Facility: .
Name System Installed Under: KU 1L;1^a, � . S)')') ►� � Type OfFacility:S�,V rn�b'�Dn'lS�
Date System Installed(Month/Date/Year): � �I �-1 Number Of Bedrooms:�Number Of F'eople:�
Is'The Facili Currentl Vacant , Ye No If Yes For How Lon � �
ty Y , g. 5-(v -' u r.5
Any Known Problems? Yes No If Yes,Explain:
Please Fill In The Following Information About The NEW Facility: .
Type Of Facility:`S l.� M 0�'J i �Q___ h(�'VL2. Number Of Bedrooms: � Number of Pi;ople�
Pool Size: Gara e Size: Other: '
Requested By: �ri�W ��' 1 c� Date Requested: i b— �3 —1��
(Signature)
For Environmental Health Office Use Only
p ed Disapproved
Comments: C�� ^t� ' S� /.b�' � /� � �C S' �-��
' i
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken a>a guarantee
(extended or limited)that the on-site wastewater system will function properly for any given period��f time.
Payment: Cash Check Money Order # Amount:$ Date:
Paid By: Received By:
Account#: �5 � ., r Invoice#: