174 Casa Bella Drive Lot 11Phone: (336) - 753 -
Davie County Health Department
mental Health Section
JH
P.O. Box 848
210 Hospital Street
Courier # : 09-40-06
tocksville, NC 27028
-kTfA—STEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
Far: (336) - 753-1680
`6 hea
Name: nI0(g � Phone Number `7 f ' 3l' Z q
S� t4,41 ( ( )
Mailing Address:L11 0 -f jq j3a /%A D 2 (Work)
�, DiP%A�re AJ e 2 -700( -
Property Address: y�?Y C 4 S +4 tie / (/4 17e 4.
Please Fill In The Following- Information About The EXISTING Facility:
Name System Installed Under:
Type Of Facility;
Date System Installed (Month/Date/Year): Number Of Bedrooms: Number Of People: I—
Is The Facility Currently Vacant? Yes �T If Yes, For How Long?
i
Any Known Problems? Yes QLo) If Yes, Explain:
Please Fill In The Follo ing Information About The NEW Facility:
Type Of Facility: J ri' Number Of Bed�joom/s: Number ,o/f People
Pool Size: /" a e, ize: Other: pl �� �`�
XRequested By: ate Requested: 0
(Signature)
For Environmental Health Office Use Only
I�Approv)Disapproved
Comments:
Environmental Health Specialist L / ate: y /'3
*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 #to 6 ?2 Amount:$ 1'019,0
Paid By: " 1( Received By: (_ oenlZy 121("w
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Account #: Invoice Invoice #: