1061 Bear Creek Church RdPhone: (336) - 753 - 6780
Davie County Health Department
Environmental Health Section
P.O. Box 818
210 Hospital Street
Courier # : 09-40-06
Mocksville, NC 27028
ON-SITE WASTEWATER
(Check One) Replacement Ren
Name:i e'vw
Mailing Address:
Detailed Directions To Site:
Property
Name System
I
The FollowingInfor-mation-About
CERTIFI ON
odelin Reconnection
Phoe Number �� Q 2' 7
Email Address:
j/� �/ Type Of Facility:_
Date System Installed (Month/Date/Year): f (� 6 (0 Number Of Bedrooms:
Is The Facility Currently Vacant? Yes to,)If Yes, For How Long?
Any Known Problems? Yes CN)oIf Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: Ptf S�9 Number Of Bedrooms:
Pool Size: Garag Size: Other:
t
Requested By
Date Reque
proved Disapproved
mments:
iYMMIM.-
Environmental Health Specialist
For Environmental Health Office Use Only
td 44
Fax: (336) - 753-1680
(Home)
Number Of People:
Number of People
W -wfic
Date:
'2—
*The signing bf 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 #: Invoice #: