124 E Robin Drive Lot 31
- Davie County Health Department
X18 I� Environmental Health Section
P.O. Box 848
210 Hospital Street
Courier # 09-40-06 1911
Mocksville,. NC 27028
Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680
(Check One) Replacement Remodeling Reconnection
Name: P:o C O ' Phone Number 4a ! 0 7 3 l (Home)
Mailing Address: �� /l.J r. ++ (Work)
V 4- 'r✓ C- C- Email Address: /o
Detailed Directions To Site:A�'
%Q
Property Address:
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: 4(. i Type Of Facility:U (�(
Date System`Installed (Month/Date/Year): (J ii lqo5—
Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes No If Yes, For How Long?
Any Known Problems? Yes 9 If Yes, Explain:
Please Fill In The 5ollowing Information About The NEW Facility:
Type Of Facility: t it' t P i Number Of Bedrooms: Number of People
Pool Size: Garage Size: + Other:
.,,Requested By G� �f� �,�,.% , w,�� - ) Date Requested:�� z
(Signatd?e) Q
For Environmental Health Office Use Only
Approved/Disapproved �l F
Comments: r
Environmental Health Specialist �� , ,d (�% f -(Cf (Y41' Date: Z�- ���
*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 heco Money Order # G Amount:$ > w Date: -7
Paid By: n PS Received By: &0111ce,
Account #:jg71y Invoice #: % O�,