180 Calvin Lane Lot 15Davie County Health. Department
4P1836,,Environmental Health Section.
P.O. Box 848
,S 210 Hospital Street
O U �'� Courier # : 09-40-06 1911
Mocksville, NC 27028
Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680
(Check One) Replac mem Remodeling Reconnection
Name: / _)0),Pf),I e� h f Phone Number _ - �L/ ` t�-r��a (Home)
Mailing Address: 3(o 1�� i�ID SL, �, �� (Work)
Email Address:
Detailed Directions To Site: 4ob_5r n .br. , 41. & 7` ,� �1 +-t
z
Property Address: ! .1 U (U t t C Gt it A((s"
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: L l� �U r G t- ,lam Aar rY '542 A)A k a'1 Type Of Facility: 1116 %, �F A/C, ol- f
Date System Installed (Month/Date/Year): i ` `1" 1 Number Of Bedrooms: 3 Number Of People:
s
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: M A', ti }, t iii L� t.n e• I�LY /70 Number Of Bedrooms: ,} Number of People_
Pool Size: Garage Size:
Requested By:—,—/
Ppm ro
Comments:
(Signature) o ' 4
Other: ` /
_Date Requested: } / Z U / 7G I1
For Environmental Health Office Use Only
Environmental Health Specialist,
Date:
*The signing of this form by the Environmental Health Staff is' fi 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 ( CasW Check Money Order #,
Paid By: Received By:�l'��
Account #: �.�� 7 Y Invoice #: }�