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748 Baileys Chapel Rd � ' �-� -� .; , � �� �� � ;� � . �,� . Davie County Health Department ���`�`S : . �P1836J� Environmental Health Section ' . . �" �- �� �i�►� � � P.O. Box 848 ��:���� � . � ~ , s„ P� � 210 Hospit�zl Street � � � O '� � la�I' Q ;.� ��;;i � Courier# : 09-40-0 1911 . � � p � � � �Mocksville, NC 270` � �CT 0 6 201 i �• av: _qy �. 1 /(,� Phone:(336)-753-6780 ON-SITE WASTEWATER CEKTI 4 Fa�c:(336)-753-1G80 (Check One) Replacement Remodeling Reconnection Name: �}p l�� l� �!i e i� y J /Z Phone Number 3��C 9 yo �2� g�(Home) Mailing Address: 7Y� �.��tv's ��i,-fjs�/ Rc� (Work) ��f�,�y,•�c.e, x�'c, �..7 G[�(o Email Address: Detailed Directions To Site: ,�1✓ 'E-X"t '7� ,�J'1'�tiyt �`1���/ �`/u�'t J� Properly Address: ���r� �✓�•�ci�s L'.��,>c/ �� 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: Is The Facility Currently Vacant? Yes No If Yes,For How Long? Any Known Problems? Yes No If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: /v �� ,s/�e� �� X'�z Number Of Bedrooms: Number of People Pool Size: Gar ge Size: Other: Requested By: L�/ �t • Date Requested: /O �G �?011 (Signature) For Environmental Health Office Use Only r � Approved Disapproved 7�Q�-� � �� � �-� l°�I`I�z°)l ments: Environmental Health Specialist Date: � ZU *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. Paymen • Cash Check Money Order # Amount:$ ) , Date: �� `L — / � Paid By: _,r����U-�✓'1� Received By: a.� ,`� � �� ''� Account#: J7(,Q g Invoice#: `�� 1 Pr�rc� 1� �1-� °o �000005 Da( ?�,�.� �77%- � � - t �7�� .,� :...:.__ ,.._.._____......... .... .... . .. .... _____ ____._. ---.-- .___.._. _.___ ._ _._._____.�..�___.___._�..�.,_�_.__ �., ' � � n ' ���// � } ��,� /��a���� FT I + ___:.��--� �3 � ; ; I � ��1� � , , ;,� � � � I �A.���1�.* '�, � s � } � �-d v���� N � a��� � /5'�� .��.-, r� j� � �s � l��l�� ..5.��'k�r' . .. .�. p�--_--..�.�,, � j t ��f�' Q�9�ry ..� ��d+ �r�f,� A� ! i / �� � � ' � — - - /Y��� �� � ; � � ; � ; ' i . � 1 � , � ; � ; : ; � �P 10 I � �� : � a�� �. ' �, ,�/ � � � 1 r� � � � � Lj�'� �<, o�. � _ . .. ,,����� / ,.. � l r�x�t7�%�"'e{i '�7`ti0�!f ` ��� i � s ��� Q G�,�'' x �-�— ; ' ., ... .,___- --� ----:,..-. ' ' � - f ��' -�. ,<< � �'T F`,�``�r,�j 1 �(� ` ���i �� e\ �� E`tG °` ��= � � r'C� � � ' � �� ��� : � � � ' � , _ .��_ .._ _ _ � i r__.. ��'�,,�--`�',��:.�-�. `�--�.. ; � - -- ; � ; ^ ' ; � i j ; i i ' ' J i ; � � —11 �D/�f' ; � � i i 1 � , � � ( � ;� �� �� ; ; I , � � �� � ; �`� i , ' � , ,.:j � �,� � � i , � �� '"'s j � \`°� i I i � , r..Y...�i . � ! � � I � I '� . �,i - ; �t � �� � � �6,• �� •�.N (� Y I � �Y' � •. � . � :�, ', . � ; � � ' � •�, ' ; � �f � Q��� � � t' __.__.___ _ _....___. _.___._._ ___._.____.___._---__�__.�___.__._._.._____ ....�_._.�__-------- — , ..-� ,��,�,. t ... , .___.. �- - �` : _ . _._._. . ___ , ' , ... .. � � � r � # r6 k�.± E .'� ,,, r,�!,�"A, f'� ` . � �,-f�-� �� 1 ., �h � ,,' i/ � � V" � � / � � �� j� ,T� �' � �.:, r Q�� �� ., '� �� . �-� �� �� f C� . � �--j �� � � � . � � � � _ � a � � �— � , � � � ,� � � � . .� �----- ' �\i � 1 � -^-� �,'�`�`� -� �-� �� _ �'�,�� � , _--_ � ____� �---._ ti� � � �' � `�' �' � _...' � �`� ` °a � �.� �� ��,� ���` a � c� - �� \�'� `�`� `� � , � ,, . � . � ,....,,.�.._- - - -- - - -------�__-.-��� ��'� ^ � Q�\e� � 'l\ � �� �c1 r � �' � �b� ��� �� � � � � 3 � �� k 3 x I ��� �_ �. ._ . s��s� � o-'C � �. ���; � " � � ` , � A� ,, � �� � � � / � � a � � � � �� �� � � � � �' _ ___ ,s � �.�-9d � �I��.t�,, - $,.�� � �.�- ,� � � Y � -ob ��'j - �.�.,. ho..� � �,.Q.. �' 31�' oa i s�' �1��� - � � ��,,L �,� �- Ur-{= � � '� �,,,C. c1�+�.E. F-� - �� 3 � �j � � c� �t� �.:..�2 �-� 1� 3� �� ���,� � -