372 Hilton Rd (2) 6
DAVIE COUNTY HEALTH DEPARTMENT
�r Environmental Health Section
�' Vv PO Box 848/210 Hospital Street
Mocksville,NC 27028
Phone: (336)751-8760
ITE STEWATER CERTIFICATION FOR DWELLING
( 1c,1 EPLACEMENT❑ REMODELING ❑ RECONNECTION.❑
Name: { c> / ✓!/ Phone Number: -�3 f(� _ � /L S�(Home)
Mailing Address:_7'Y Z ,>'`-i' Z TG" A//2J , (work)
Detailed Directions To Site: "A ✓ �1 /U/�e ',f r t7 � '%/G� ^;�
v
Property Address:
Please Fill In The Following Information About The Existing Dwelling:
Name System Installed Under: C y ( ;A ✓ , 7G� Type Of Dwelling:-��
Date System Installed(Month/Day/Year): ' c Number Of Bedrooms: :P Number Of People:
Is The Dwelling Currently Vacant? Yes ,J"NNo If Yes,For How Long?
Any Known Problems?Yes❑ No�%wIf Yes,Explain:
Please Fill In The Following Information About The New Dwelling:
Type Of Dwellin001 61; li 16" Number.Q#-Bedxc�ms: C Number flf-People �Or C1 e
Requested By: Date Requested#�
{Signature)
For Environmental Health Office Use Only
Approved Q' Disapproved 0
Comments:
Environmental Health Specialist Date��J�-
*The signing of this form by the EnvironmenlKI 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: $ d Date:
Paid By: r� Received By:
Account #: 25 Invoice #: k7l