255 Leisure Ln Davie County Health Department
'D 1836j� Environmental Health Section
P.O. Box 848
210 Hospital Street
O U Courier# : 09-40-06 1911
Mocksville, NC 27028
Phone:(336)-753-6780 ON-SIT EWATER CERTIFICATION Fax:(336)-753-1680
(Check One Replacement Remodeling� Reconnection- ��_�Q�✓
Name:-/—". 1 VI 1_l — C-6—ran Phone Number (.3 O ���'�3 c�� (Home)
Mailing Address:a5.6-- L21'sUr a,/Lh (Work)
AA12('8S iii1t, Email Address:
Detailed Directions To Site: (DC)
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Property Address: le/.Sure- /�,. YIQ it h�y►�Ie .
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under:r ,�a1� Type Of Facility: f/)q1�4�&�
Date System Installed(Month/Date/Year): �q (1Number Of Bedrooms: :ZfNumber Of People:
Is The Facility Currently Vacant? Yes 10 If Yes,For How Long?
Any Known Problems? Yes G If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: Np u) (�(t�ZI w ti e, Number Of Bedrooms: Number of People
Pool Size: Garage Size: Other:
Requested By: t � �dA � Date Requested: /
(Signature)
For Environmental Health Office Use Only
Approved Disapproved
Comments: /
.. --
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health S ff is in no way intended,nor should be taken as a guarantee
(extended or limited)t� t the on-site wastewater system will function properly for any given period of time.
Payment: Cash ck Money Order # Amount:$ .(w Date:
i f
Paid By: Received By: L&�Wu'�
Account#: _ � �� Invoice#: