149 Casa Bella Drive Lot 6N
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DAVIE COUNTY HEALTH DEPARTMENT I
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATE CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT REMODELING ❑ RECONNECTION ❑
Number., � � t � 5�1 6 y c.ZGe-J (Home)
(Work)
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Please Fill In The Following Information About The Existing Dwelling:
Name System Installed Under: Type Of Dwelling:7 r)
Date System Installed(Month/Day/Year): Number Of Bedrooms: 2— Number Of People: l
Is The Dwelling Currently Vacant? Yes ❑ No b' If Yes, For How Long?
Any Known Problems? Yes ❑ No 9—Iffi Yes, Explain:
Please Fill In The Following Information About The New Dwelling:
Type Of Dwelling: P Number Of Bedrooms: Number Of People:
Requested B = ___ �� ��. \I .'�--� �—'' Date Requested:
For Environmental Health Office Use Only
t pproved ] Disapproved ❑
Environmental Health
I
*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 ❑ Check ❑ Money Order ❑ # Amount: $ Date:
Paid By: Received By:
Account #: tit l> �7 Invoice #: C
Detailed Directions To Site:
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Please Fill In The Following Information About The Existing Dwelling:
Name System Installed Under: Type Of Dwelling:7 r)
Date System Installed(Month/Day/Year): Number Of Bedrooms: 2— Number Of People: l
Is The Dwelling Currently Vacant? Yes ❑ No b' If Yes, For How Long?
Any Known Problems? Yes ❑ No 9—Iffi Yes, Explain:
Please Fill In The Following Information About The New Dwelling:
Type Of Dwelling: P Number Of Bedrooms: Number Of People:
Requested B = ___ �� ��. \I .'�--� �—'' Date Requested:
For Environmental Health Office Use Only
t pproved ] Disapproved ❑
Environmental Health
I
*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 ❑ Check ❑ Money Order ❑ # Amount: $ Date:
Paid By: Received By:
Account #: tit l> �7 Invoice #: C