274 Riverdale Rd (3)L
Phone: (336) - 753 - 6780
Davie County Health Department
Environmental Health Section
1 C'StO
P.O. Box 848
210 Hospital Street
Courier #: 09-40-06
Mocksville, NC 27028
ON-SITE WASTEWATER CERTIFICATION
Far. (336) - 753-1680
(Check One) Replacement Remodeling Reconnection
Name: Phone NumbeV 7 3� 9-({- 9 4 `d a (Home)
MailingAddress: v2% ✓Q 2 (Work)
Ann(.fS\jd1rz PJC 'D.,702%Email Address:
Detailed Directions To
Al
Please Fill In The Following Information
/About T,h/e E �S[TING Facility: u
Name System Installed Under: c,%C�i)1�t �G � /7 Type Of Facility: s vi /
Date System Installed (Month/Date/Year): / Number Of Bedrooms: 3 Number Of People:
Is The Facility Currently Vacant? �Yes� No If Yes, For How
(No
Any Known Problems? Yes Ij Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: 11 I/ e" Number Of Bedrooms:_12�__NumberofPeople
__
Pool Size: / Garage Size: Other:
)Requested By: 'y A,L 2 .L w Date Requested: 16 —/y ` / S
(Si' atur
For Environmental Health Office Use Only
Approved Disapproved
Environmental Health
*The signing of this form by the Environmental Health Staff is in no way intended, nor
(extended or limited) that the on-site wastewater system will function properly for
Payment: Cash,,�,Check ),Money, Order #_
Paid By:_
Account #:
Received By:_
Invoice #:
as a guarantee
any given period of time.
Gr v, ayrcan ac ingrMs
avel Drive Crosses PA 0,7• Reference DB 103 O PG 109
a EIP Fnd 4 Q f
Shedl-""1 i IRS
..+..-.1 . 5/81, EIR Fnd
-� Gravel Drive Shed - - - _ _ _ - T-8
Shed -; _ _ _
--__-
___-Grav_e{Drfve-------------
Well
__ _ _-_-_ Weil House Well House - - - - - - - - - - - - -
o Crosses P/L ~ RRS Fnd 0 Approximate
\ I - North EP ad S.R. 1100
it (\ Tax lot 57
Tax Lot 58 'f: Tax Map N-6 /
Tax Ma N-15 n/1 Alfred T. aywal tt
n P&Hellen C. Daywalt
0.773 Acres 08 112 O PG 179
Tax Lot 58.01 W
/
Tax Map N-6 Riverdale Road
i
/ 1
2.594 Acres +/— i" EIP Fnd --- e / / S.R. 1100
00 t
) N
ta0 60' Public R/W 16'+/— Pavement Width
Tax. Lot 59
�+ Tax Map N-6
n/f Denny 0. Seamon RRS Fnd 0 Approximate
WB 1999 O P%1277 C/L of S.R. 1100
it/f nd, 3/4" EIP Fnd F EIP Bent/Fnd DB 181 O PG8-- -- -
lQ :-2 .L_1 TT4 1" EIP Fnd 7-3
i � foot
J foc
OC
I '
O7e)
v
Tax Lot 60
Tax Mop N-6
i...
n/f Joseph L Smith ' Survey for.
&Dorothy Smith
. DB 48 O PG 32 3 w w
a� Ralph
NCGS Monument "TARA AZMK" TT
N: I KRI 8.33' Rr H n7'1
r.N: b441 6.341.r