1647 Underpass Rd4 3 4t, Z V d
Davie County Health Department -,%"
4ivlt� Environmental Health Section Al,
P.Q. BOX 848
210 Hospital Street ^
Q '.,'� Courier # : 09-40-06
Mocksville, NC 27028
Phone: (336) - 753 - 6780 Fax: (336) - 753-1630
ON-SITE WASTEWA�e=modefing
TION
(Check One) Replacement econnection
Name:(A0. ri "Zt1 Phone Number �% %/� (Home)
Mailing Address: / (Work)
Vl Email Address: -� bpT�T0Z J/2G,A-VAi�
Detailed Directions To Site: fZJ•�
.1A VI c P . ,..
Property
Please Fill In The Followin Information About The EXISTING Facility:
Name System Installed Under: �� (� 1V %I(/ w Type Of Facility:(InIM 5 p
Date System Installed (Month/Date/Year): b 7 Number Of Bedrooms:__3 Number Of People:
Is The Facility Currently Vacant? Yes Q If Yes, For How Long? �U��° pis /� f (xOwe
Any Known Problems? Yes S If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: 510 rn��Number Of Bedrooms: Number of People
Pool Size: Garage Size: Other: Z !aE
Requested By: _ Date Requested: 5LOC:)17
(Cion �rPl
For Environmental Health Office Use Only
P.LsApproveapproFT ry a i�TJ ved ` `� `
Comments: prDay-e + 1 r � bA I � I M' rla rpLI n 4 o/"
FN
Health Specialist
Date:
*The signing of this form by the Environment,"ealth 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:$
Paid By: Received By:_
Account #: Invoice #:
Date:
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