223 Gillbert RdDavie County Health Department
P8 t� Environmental Health Section '
� P.O. Box 848 I
210 Hospital Street
p Courier # : 09-40-06
Mocksville, NC 27028
Phone: (336) - 753 - 6780 Fax: (336) - 753-1680
ON-SITE WASTEWA CERTIFICATION
(Check One) Replacement Remode in Reconnection
Name: r1 Pib h/� 1�i�1�r I%pr� 1 Phone Number — 65 I �� / (Home)
Mailing Address: �Q 3� /'i1 � 8hck x101 ALZt�,lv54 (Work)
N- ,�,-7�n15 Email Address: n1!.1-F�011 i�� CIOI CE�h'l
Detailed Directions To Site: 67) j h,,;?c4- Rd,kjoyi') )e i /U e
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: 11l 1jj�ffiType Of Facility: JF
Date System Installed (Month/Date/Year): Number Of Bedrooms:___y Number Of People: O�
Is The Facility Currently Vacant? Yes 00
Any Known Problems? Yes 0 If Yes,
If Yes, For How Long?
Please Fill In The Following Information About The NEW Facility: e�{'VIOpG(/n� ((idhw ue ql`e
Type Of Facility: a+ ( I (lLlra(e C C)T► 1a Number Of Bedrooms:�_Number of People_��
Pool Size: A) A- Y Garage Size: , I_ (� Other:
Renuested Bv: i- , �i�10.%74 l E}'1 Date Requested:
For Environmental Health Office Use Only
Approved Disapproved
-gimme s:
Environmental Health Specialist `/�}� , , n _ _ Date: (o—T/j /6
*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.
Payment: Cash Check
Paid By:_
Account #:
Money Order # Amount:$ Date:
Received By:
ice #: