2013 Hwy 801S (2)M
Phone: (336) - 753 - 6780
Davie County Health Department
Environmental Health SectiQn
P.O. Box 848 Date; -PAID
RECEIVED 210 Hospital Stre 1 �l
Courier #: 09-40-0 eCetved b ;
Date: 21 Mocksville, NC' 27028
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Fax: (336) - 753-1680
Name: !Sfelrl u -A- 06060y) 0y) t ■ y F-IQI'(CI Phone Number 33(p` gyd`�p33 jpIoriE m+ )
Mailing Address: T, 0, �c-�) Q 3&0-'330-c;).5-30 L- mil (Work)
c��� () . Email Address: ry nee- em i �°ss; ,, ,CGr'1
Detailed Directions To Site: L123Y 17�QY
Property Address: /UC qQ1 fl � a Derv% e
Please Fill In The Following Information About The EXISTING Facility: � IZD' 066.3ZO
t?/
Name System Installed Under: ? S Type Of Facility
Date System Installed (Month/Date/Year): /"/ Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes No
If Yes, For How Long?
Any Known Problems? Yes 0 If Yes, Explain:
Please Fill In The Following Information About The NEW
/W Facility:
Type Of Facility: i anu � t 0 I�e �7 X Z`1 Number Of Bedrooms:_�Number of People
Pool Size: - Garage Size�: / Other: 1tc t i 14 ( Y -Z. l i X cZ
Requested By: /Lt�l� Cil g 4 " Date Requested: j' -off-
(Signature)
Approved / Disapproved
For Environmental Health Office Use Only
Environmental Health Specialist ��,��� Date: �"02
*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:$
Paid By: Received By:
Account #: M50 5' Invoice #: (� Gj
Page 1 of 1
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Parcel Number:
G8120B000201
PIN Number:
5880209510
Account Number
41012000
Listed Owner # 1:
MAR.KLAND CARLETON l
112
Listed Owner #2:
AARKLA.NO SHIRLEY W
105
Mailing Address 1:
0 0 BOX 2142
Mailing Address 2:
oty:
ADVANCE
State:
!,C
I O Zip Code:
�i ,A
21005-0000
Legal Description:
: LCT PEOPLES CREEK R
_ - Acreage;
1,28
1
L00000
it
�o m
58 ft
Lititudc 35156 28,53' Longitude: -80124 31,08'
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5/20/2014