546 Four Corners Rd (2)Phone: (336) - 753 - 6780
Davie County Health Department
Environmental Health Section
P.O. Box 848 4
210 Hospital Street
Courier #: 09-40-06 j gfi q
Mocksville, NC 27028
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Fax: (336) - 753-1680
Name: n 0, , 1" l� I 1 Phone Number ✓.-_�.() ' ��3 (Home)
Mailing Address ,,2 t(Q F pur Corners m f (Work)
tacK ICS 6\ u- l c X70@00 Email Address:
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Detailed Directions To Site: kay, e 152 \ �C y QU-M \) 0,4 - iQ)(e K -I Q 4
Ur Cocrer
I -1)u r D it l
Property Address:
Please Fill In The Following Information About The EXISTING Facility: �i
Name System Installed Under: 11 & a -e � 5, �10 L _I_ Type Of Facility: f)), 0 Q 1 Q T a t"r"1l It,
( orm L'
Date System Installed (Month/Date/Year): " 1 (ILI Number Of Bedrooms: Number Of People: e�
Is The Facility Currently Vacant? Yes G If Yes, For How
Any Known Problems? Yes Ivo/ If Yes,
Please Fill In The Following Information About The NEW Facility:
Of Bedrooms: Number of People D
Type Of Facility: M(Vy o m
J
Pool Size: � A Garage Size: 4V
Requested By:
(Signature)
Environmental Health
For Environmental Health Office Use Only
Date:
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
Davie County Health Department
Environmental Health Section
P.O. Box 848
210 Hospital Street ct6
Courier #: 09-40-06
Mocksville, NC 27028
Phone: (336) - 753 - 6780 Fax: (336) - 753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: : �`�I ,, i ( I/1 [p p J V la m P 14 o I f Phone Number (Home)
Mailing Address: .5-1/b /Fo u t roy n r v ed (Work)
A4 G C / 6 u i 41,.e rNr a� -rev G Email Address:
�
Detailed Directions To
Property Address: eO ti � v { ,2 '7'Q
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: R .-e 1 e C-9/ tjo t—r Type Of Facility: 5 -7 -
Date
Date System Installed (Month/Date/Year): —Number Of Bedrooms: i�L Number Of People:
Is The Facility Currently Vacant? Yes J�' If Yes, For How Long?
Any Known Problems? Yes 61 If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: 5,C— Number Of Bedrooms:__)L- Number of People
Pool Size: Garage Size: Other:
Requested By: K Date Requested:
For Environmental Health Office Use Only
Environmental Health Specialist Date: :5-- 38 / -'�
*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 #_
Paid Bv:
Account