1447 County Line RdDavie County Health Department
3(N0'36 Environmental. Health Section
P.O. Box 848
210 Hospital Street
Courier # : 09.40-06 c i
Mocksville, NC 27028
Phone: (336) - 753 - 6780 Fax: (336) - 753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
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Mailing Address: ` Q y� f ?/ (Work)
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Detailed Directions To Site:
Property Address:
Please Fill In The Following Information About The
EXISTING Facility:
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Name System Installed Under: ewmp Type Of Facility:_ d ��
Date System Installed (Month/Date/Year): &>: Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes /Na J If Yes, For How Long?
Any Known Problems? Yes S
If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: tt Number Of Bedrooms; r Number of People.
Pool Size: Garage Size: Other:
Requested By:
Date Requested:
(Signature)
For Environmental Health Office Use Only
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ed Disapproved41-014ats. V 15 Aug
Environmental Health Specialist
Payment: Cash Check Money Order # Amount:$ Date:.
Paid By:
Account #:
Received By:.
Invoice #: