146 Roberson Dr County Health Department
ronmental Health Section ' ;
P.O. Box 848 3`A k
c' 210 Hospital Street
U ° VIRONPJ�ENTA�H��TH Courier# : 09-40-06
EN
" DA\'�ECODv1Y Mocksville, NC 27028
Phone:(336)-753-6780 Far:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION F� LING
(Check One) Replacement Remodeling Reconnection
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Name: 6f e ti ti S • VV,o7'-'r Phone Number 3 G " 7 S " -7 3 L (Home)
Mailing Address: /y�/ R�hPr s0�, �r, 3w - ��1 Z 3 7r) (Work)
X70dssVr//L' Al C_ 270 7-k
Detailed Directions To Site: 4!9 /r ftp,., c �� L/1,•rr'�S
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Property Address: -S'4 #i e- 4
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: lrr c s S. (it/ur >n Type Of Facility:P0a 1411e �✓i c✓
Date System Installed(M onth/Date/Year)��nrrr,rte` Number Of Bedrooms: 3 Number Of People: 3
Is The,,,Facility Currently Vacant? Yes If Yes,For How Long?
Any Known Problems? Yes N If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility:_ /10 Q k �4,' /a m L Number Of Bedrooms: 3 Number of People 3
Pool Size: Garage Size: Other:
Requested By: Date Requested:
(Signature)
For Environmental Health Office Use Only
�pprovedisapproved
Comments:
Environmental Health Specialist Date:
*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:$ 0 d Date:
Paid By: f Received By: `L 1t fpl
Account#: �j5g3 Invoice#: 70
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http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 10/4/2010