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681 Bear Creek Church Rd Davie County, NC Tax Parcel Report J-13 I Monday, September 26, 2016 785- , (76 2 f/ t i�76 5}� 7k 1 773 r 733 712 X7.00 ' 666 f656 x, Jt 1" -'z , 156 WARNING: THIS IS NOT A SURVEY Parcel Infortion Parcel Number: D200000017 Township: Clarksville NCPIN Number: 5802708252 Municipality: Account Number: 82518076 Census Tract: 37059-801 Listed Owner 1: CARNEY SAUNDRA K Voting Precinct: CLARKSVILLE Mailing Address 1: 681 BEAR CREEK CHURCH ROAD Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A,R-20 State: NC Zoning Overlay: Zip Code: 27028-0000 Voluntary Ag.District: Yes Legal Description: 38.445 AC BEAR CREEK CHR Fire Response District: WILLIAM R. DAVIE,SHEFFIELD-CALAHALN Assessed Acreage: 37.90 Elementary School Zone: WILLIAM R DAVIE Deed Date: 12/2004 Middle School Zone: NORTH DAVIE Deed Book/Page: 005850744 Soil Types: MnC2,MnB2,MdD,ChA Plat Book: Flood Zone: Plat Page: Watershed Overlay DAVIE COUNTY Building Value: 265780.00 Outbuilding&Extra 8320.00 Freatures Value: Land Value: 248660.00 Total Market Value: 522760.00 Total Assessed Value: 522760.00 161 C NAlldataIsprovided as Is without warranty or guarantee of any kind either expressed or Implied including but not limited to the Davie County, Implied warranties of merchantability orfitness for a particular use.All users of Davie County's GIS websIte shall hold harmless the County of Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to C or arising out of the use or inability to use the GIS data provided by this website. DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 0 r Q�tl� �5(� Account #: 990003411 Tax PIN/EH#: 5802-70-8252 dJ 110 5 Billed To: Saundra Carney Subdivision Info: Reference Name: Location/Address: Bear Creek Church Road-27028 Proposed Facility Residence Property Size: 40 acres As stated in11 '1g, �4 18A.1969(5) ATC Number: 3931 accepted Sysl--,As Ir}tiy also be used AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Se ge Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEW R I N IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur Date: /0J CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit [f�� has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and 3- Disposal Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any 73 given period of ame. ` �-� - �00 L M � C% q , Ire-jT Ql�ic,1 N s4-b c Septic System Insta Environmental Health Specialist's Signature: Date: / ©(o DCHD 05/99(Revised) - - • • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990003411 Tax PIN/EH M 5802-70-8252 Billed To: Saundra Carney Subdivision Info: Reference Name: Location/Address: Bear Creek Church Road-27028 Proposed Facility Residence Property Size: 40 acres ATC Number: 3931 **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this ti Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type 6 00S l; #People 2 #Bedrooms #Baths 2 •`j Dishwasher. d Garbage Disposal: ❑ Washing Machine: Er Basement w/Plumbing: Er Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:❑ Lot Size ACQGS Type Water Supply 00-l-- Design Wastewater Flow(GPD) 4W Site: New Ef Repair❑ System:Specifications: Tank Size 1000 GAL. Pump Tank GAL. Trench Width!&;' Rock Depth 17-" Linear Ft. �! As stated in 15A NCAC 18A.1969(5) Other: bism 6o I-1.0i accepted Systems may also be used Requ Site Modifications/Conditions: 11J%jTSL3O►J CLQ, V=---P ICO' g4ZQ l aA--t V-44 41MOVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m.to 9:30 a.m.or 1:00 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** ts Sr�AQ�"f1oA � i `b, �,k`ri qts Rvj lsk)D P,4,.,r A �� � A c 5a' Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) _ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • P.O.Boa 848/210 Hospital Street a ` Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990003411 Tax PIN/EH#: 5802-70-8252 Billed To: Saundra Carney Subdivision Info: Reference Name: Location/Address: Bear Creek Church Road-27028 Proposed Facility Residence Property Size: 40 acres ATC Number: 3931 •u **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tai►k's*stem or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People 2- #Bedrooms #Baths �2•� Dishwasher: Er Garbage Disposal: ❑ Washing Machine: CT— Basement w/Plumbing: Er"'—Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 40 A '� Type Water Supply�.t�El-1... Design Wastewater Flow(GPD) 1" Site: New If Repair❑ System Specifications: Tank Size 1000 GAL. Pump Tank GAL. Trench Width -50 Rock Depth 12" Linear Ft.�D� Other: -s- PZSSTQI60TIO &eiGr-,S Required Site Modifications/Conditions: I rJSTALL, 01,3 CE)rJT9lZ_ Ku----P IOG P-&-- Oa4-19 IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** 115ET qec4Ico POMP fivQ 12& I &%se n aT PLO 120'x3ce"��2" I RUc)L- �' t_�5 �►� r ' ar,&Ir')ZD, FST �V(.1n/J']n� � OI dP�•��� �$ya n� S Baa Mop. u-jF- .410r1 Environmental Health Specialist's Signature: Date: ® 4 r DCHD 05/99(Revised) 1 ° DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003411 Tax PIN/EH#: 5802-70-8252 Billed To: Saundra Carney Subdivision Info: Reference Name: Location/Address: Bear Creek Church Road-27028 Proposed Facility Residence Property Size: 40 acres ATC Number: 3931 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRU TON IS VAL/DOR PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: e: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) scat �� Q� 4r APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMI C NOV 15- Davie County Health Department $ Environmental Heaith Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVIRONMENTAL HEALTH (336)751-8760 DMIECOMN ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refe�rL to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �V. �1•. p�e�' Contact Person J Ql1�V�L�Cf�A Mailing Address V K(,6 Q�`+ Home Phone 3:,3 /D—23(0 7 City/State/ZIP \OC��J��` QVC ��b� Business Phone '7bY— 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: QrSite Evaluation E tyImprovement Permit/ATC 2 Both ti 4. System to Service: VHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: IYConventional ❑ conventional modified ❑ innovative 6. if Residence: # People # Bedrooms # Bathrooms C) /a Diahwasher ❑Garbage Disposal Gashing Machine (�asement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People �# Sinks # Commodes # Showers # Urinals' # Water Coolers IF FOODSERVICE: # Seats Estimated Water,Usage (gallons per day) 8. Type of water supply: ❑ County/City 11e11 ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes a<o If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLATS torr SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: `'t UC`CA`s WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # -70- Irl�2 �0�4 o �� r�t, (' Property Address: Road Name lbe c,- Vt QP-ayttCC\,1 city/zip o A R . ��- �_ os� �emr C_ree<< C- -cL�` If in a Subdivision provide information,as follows: IL Name: CA <Sn166 — k—XX\-,Q. Section: Block: Lot: Date home corners flagged: //• �G`0 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or changed. I,also,understand that I alit responsible for all charges,incurred frons Misapplication. I,hereby,give consent to the Authorized Representative of the Davie County IIealth epartment to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE 1( 1 I S D SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). S"s/z w-44 I`/`4 6s�lj► / k .� S Site Revisit Charge �7 Date(s): Sly � /sl f /�61 Client Notification Date: EHS: Sign given ` Account No. { I Revised DCHD(05/03 C � �s Invoice No. 594 �. l.Js', c'V7) Lt ��a,�,q per(y��'- _ � ,.c„'' •Y �rr�= l�rt tti- 4c.,}!�'fi }�'. �+^ 42"�5..3ti�'^ ! R� •-z7r +" r`,v<•1ri.. S - �w �' h - '„' � eiv .fi�J - `°1" 4'n43.ts, yFri �} f •, �� F was,Fhb - M i'"' r ' F --`%'�' -y`.`- ,•3� 6. syr �'"C `�r'E'a�,�,��_s.? +�-__^r r�-yY}_i '�.+ ��z 1 jai�"� � ,a'-K'S�•yr�'"�'e'�r - - :_` N i a t� �4"'fes•, �':. s¢ a ��� � , z- Fs, �- t r c is � ti (259) 259.91 � 1 • f / i ` T -F 4ILL c' O.. 40 . 2 Ac :' ry — tY4 66.6 } will% `. s PHOTOGRAPHY BY T c T � Nv s� oac _ wP� DAVIE COUNTY HEALTH DEPARTMENT , • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003411 Tax PIN/EH#: 5802-70-8252 Billed To: Saundra Carney Subdivision Info: Reference Name: Location/Address: Bear Creek Church Road-27028 Proposed Facility'; Residence Property Size: 40 acres Date Evaluated: 2 Water Supply: ,On'-Site Well y/0' Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 L Landscapeposition (CV 'L L L L C✓ Slope% 4jo (p '' ) _g- HORIZON I DEPTH O - - ��-t - t 2 - Uo - 1 Texture groupS'�C_ iG C L CL_' Consistence ' S S'S ' Structure c < A SS7 A3ic Mineralogy ,Gil HORIZON II DEPTH 24- LP i l2 - -32_ - Jq-4 y_ Texture group .1 (S;`t 4 C, '.C i C- P Consistence ' S P Structure Ask Mineralogy 5 HORIZON III DEPTH 2 �p -Cl / -qk Texture group C-► t s.j 5;C+S Consistence G- F,- S P F SN Structure L 43k Mineralogy L HORIZON IV DEPTH Texture group �•t�� Consistence Cr S Structure g) Mineralogy �< SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE v CLASSIFICATION 05 0S i V 5 pS LONG-TERM ACCEPTANCE RATE 0-t5.03 O• EJ•Z"1 0• b. ,?�( SITE CLASSIFICATION: EVALUATION BY: -� LONG-TERM ACCEPTANCE RATE: J OTHER(S)PRESENT: REMARKS: 2jC nvTTjLi•J(� y4''s A+i s� /✓� �1CsE � LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope. :% ;FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T Terrace FP-Flood plain H-Head slope Texture S-Sand :LS-Loamy sand SL-Sandy loam L-Loam SI Silt SILL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist ; .VFR-Very,friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic- P-Plastic VP-Very plastic Structure, SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky , PL-Platy PR-Prismatic Mineralogy 1:1,2:1,Mixed Notes t ' Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gal/day/ft2 DCHD 05/99(Revised) ■■s■■a■■■■■■■cee■■■■e■■■■■■■■■e■■eeee■■ee■■e■■e■se■ees■■e■■■ecce■■ ■e■■■■e■■■■■ee■■■s■■e■■■■■■■■■■■�ieee■■ee■■■■■■■■■e■■■■■■■■■eeee■■ ■■■e■■■■ace■■■■e■■■■s■■ce■■■■e■■■■■■■ee■e■■■■e■ceesec■■e■ee■e■■ee■ ■■e■■■ace■■e■■■■■■■■e■■■■e■■■■■■■■■■■■■■■e■■■■■■■■■■■■■■e■■■■■■■■■ ■ee■■see■■eece■■■■e■■s■■■■e■■eeee■■■■■■e■■e■eeee■■eeeee■■eeeeeeee■ ■■■■■■■e■■eseee■■■■■■s■■e■■■ee■■e■■���■■■ee■■■e■■e■■eeee■e■■eeee■■■ ■■■■s■■■■■s■/■■/■/■■■■/■■■■n■I►see.._►s■■■■■■/■■■■■■■■■■■■■■/■■/■■■■■ ■■■■e■s■■eeee■■■■■■e■■■e■■■c.u�tiourtr�►]eeee■e■■■e■■e■■■■■eeee■■■■ee■ ■■■esee■■■ee■■■■■ee■■es=e■■■■■■■■ ■■■■■■e■■■■■■■■■e■■■■eeeee■■■■■a ■■■■■■■■■ca■■■�e■e■■■■■■e■e►eecr■ei■ec:■c�::T.■eeee■■■a■■■ee■■■■ee■ ■eco..:�■■�■■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■�i•.�:�■.���■■■■■■■■e■■■■ ■elieee■■e■■■ee■■■■■■■■■■■e■■a■eee■■■■■■ee■e■ee■eeln■■■�■■■■■■■■■■■■■ ■■■ee■eee■■■■■■e■■■■■■ace■■■■■■■■■■■■■■■ir:■■■iiet��.►7■■■■■e■■■■eee■■ ■■■eeeee■ce■■■■■■e■■■■ace■■ecce■e■ecec■■lec■■■eeeeee■■ee�■e■■■eeee■ ■e■e■■■■■■■■■eeee■e■■■■e■eee■■■■�i■■■■■■le■■ce■ecee■ee■■e■�■ese■■s■■ ■eeaes■■■caeca■■■■■■■e■s■■■■■e■■■eee■■e■I■■■■e■■■■■■■■■e■laa■■■s■■■■ ■■see■■■s■aa■■e■■■■a■■■■■e■■■e■■■■e■■■a■I■■a■e■■■■■e■■ae■■r�■■■■e■s■ ■■■ae■■■■eee■■■■■■■■■■■■■■■■■■■■■■■■■■■■In/a■c��■■■■■■a■■■��■/■s■■■ ■■eeee■■a■sea■■■■■■■■■■■■■■■■■■a�■■a■■■■II/rf;■■��.■■■■■■■■■■■yea■■■■■ ■ee■■■■■ee■■■■■■■eee■■■■a■■■■a■■iia■eeee■I■�e■a■■■■■■■■■■■a■�■■■s■■■ ■acaeea■■■■■■eeee■■■■■■■■eeecee■►�e■■■■e■I■e■acee■e■ece■■eeee�■e■ee■ ■■■ae■cess■■aa■a■e■■■ae■■:.■ae■■al��la■■■s■I■eaaae■aaa■■a■■■■■a��■■■■■■ a■■■■a■ee■■■■■■■■■■■■■■■■■��■■■■ ■■■■a■i■■■eee■■■■■■■ae■■e■�i■■■■■■ ■■e■a■sa■aaeaaa■■eaaeaee■a■eeee■ua■■■■a■leae■ae■aa■aa■aaaaee��a■■a■ ■■■e■■■ae■■ere■■a■■■■■■■■■e■■s■■a■■■■■■r�r�rt■■■ea■a■■■■■■■■a■ari■■■■■ ■ee■■eeee■■■■■■e■■■■■■■■■■■■■■■■t�■■■■■■■,..I,ea■■a■■a■■■■ee■e■e■■■■■■ ■■■a■a■■■■sa■■■a■■a■■■se■■■■s■■orglees■s■■I■a■■►■�■a■■■■■■■■■■■�.■■■■■ eeee■■■■a■■■■■■■■■■■■■■■■■■■■■■■�■■s■u>tl■■■■■■■■■■■■■■■■■■■■a■a■■■ ■eeee■■■a■►■■■■■■a■■■■■a■■eee■■■■�a■■■■■■les■■■■■■■■■■■■■■■■■■�■■■■■ ■■easee■■e;e_�■■■■►.��■■■aaa■■■■■■epee■■as■I■■aa■■■■■■■e■■■■aa■air.■■■a■ ■eeee■■a■■�■■■■■�I<lease■■■■■■■■■a■■■■■■■i■■■aa■■s■■■■■■■■■■■■c�■a■■■ ■e■aea■■■■�a■■■■■s■■■■■■■■ri:eco::::::::�i■■■■■■■■a■■ae■■■■■■■r�■■■■■ ■a■ae■■e■c■■■a■aa■■eeee■■■I■■■■■■a■■■■■■Ilaa■ae■a■■a■■■■■■■e■■►i■■■■■ ■■■■.el�i■aeeea ■c■e■el■■e■■la►_iii!► eeil ■e■■■■ ■e■■■aaa■■ee�i ■■■■■■�\!ilt■e■■■■�'!1■!1■■■■■■I■■■■■'JL'Oi�iOr■■11■■■■■■■■■■■■■■■■■■■■i■■■■■ eeee■■/`irJ■■C•■L'[�tii1■[iI1�Gj■I■eeee■■e■eee■11■■■■■■■■■■■■■aa■■■■■IJ■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ill■■1■■■■/1►�Il��1i1711 vii■■■■■■■■■■■\1■■■■■ ■■■■■■■■■■■■■■■■■■■■■eee■■■■■■■■a■■■■■■■tliiiiifi:%■,L'�■■■e■■■■e■e1/■■■■■ ■■■■■eee■■■■■■■■■a■■■■aa■■■■■■■■�■■■■■■■s■■■s■■■n■■ne■■■■■■■■■■■■ ■■e■e■e■■■■e■■s■■e■e■i`e■■■ (,11v71\tl■/I:I■■■■t'\■■■■■ ■aa■■o�■aa■eeee;vie■eee■■ea■■■■■■►,�■e■■e■�■■ee■e■ea■■■■■■■■■ee■■e■s ■e■■■i■■■■■■■ease■■e■a■■■■■■■■■■l��i■■■■■e■■■■■■■■■■■■■■■■■■■c■■■■■■ ■■■aI■see■■■ea■■■■■I/7■■■■■alt■■a■■■■■■■eee■■■■■■■■■■■■■■■aa■/Ie■■■a■ ■■■■/1■■■■■■■■■:CGG�GGGGGGD.:I'1�■i■e■■ie■■■ei■■■e■■■■ee■■e■ee■■i■eee■e■ ■ea■aase■■■■■■aaae■a■■eee■■■rlls■■■■■■■a■aa■as■e■ee■■■■■■■■■■�■■■aa■ ■eee■■aaaaaaae■■a■■■■a■■■■■a■■aa■■■■eeaaaaaeeeaaaaa■■■aaasaa■aaae■ ■■■■■■■■a■■■■■■a■ea■■■■■■■caeca■�i■■ae■■■■■■■a■■■■■■■■■■aaaeaa■■a■ ■■aceeea■■■■■■■■■■e■■■e!►eeee■■ee■■eee■■ee■■■■eee■ee■■■eee■■ec■■e■ ■■a■ea■aeea■ae■as■a■e■a■■a■eee■■■■■■ea■■eeeee■ae■aaaa■■■■eeec■aac■ ■■■■eeee■■■e■■a■■■■■■■■■■■■■■■■■■■■■a■■■■■■■■■■■■■■a■■■■■■■■■■■■■■ ea■aeec■aa■■■a■eeee■eee■■■■■■■■■e■■■■■■■■■■■s■■■■■a■■■■■aa■■■■■■■■ ■■a■eae■■ae■■a■■■■ae■■aa■eeee■■■�i■■eee■a■■■■■■■■■aaa■■ee■e■■■■■■■ ooe ' Y r �',• ) • ) r ` 9799' _ •1 8793 co s nC2 �h ,' ,. 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Les Fpk Se,� ee-eek cA. ,Z�l. ^r /,.�.•� Gl ' fel► £Ov f.tl t'W-F>*` -A'jiEY! V'i;6L,4 fD. 74on NA'.16 W vr54te Property Addresa: j�t3/ R c..r s fit:_ ,r Eel,,- Please bill In The Following Information About The EXISTING Facpity: Name System Installed Under-JgSv y. ra C a r-.tie.✓ Type Of Facility: Rev u% Date System l'nstslled(Month/Date/Year):_ T—Number Oi'Bedrooms: H Number Of People: z IS The Facility Urrently Vacant? Yes:] NoE(( If Yes.For Flow Long?_,.,_ - M4.14 144"e- . Any Knows P=blc=? Ycs D NoC✓If Yes,Explain: _ Please.Fill In The Following Informal ion About The NEW Facility: Type Of Facility: Number Of Rcdrooms:_ Number of people Requested By:_�-✓ - Date Requested: (Signature) For rrnvironerutal HealthOt3'tce iJSC Only Approved Disapproved 0 m Comments:_l-l- St% LCQ CVW, N-4Ifu"I ES Va Jh. OkFL-\Q-t✓ Of -IX,414 1,&5(M A ekc) W &R4JL-0,-- A-Aq� C.o�lS� s Environmental Health Specialist Dater (.0- -WC sighing of ibis form by the finvirmmental Hikifillifrkinrino,WaY inten ed norshould be taken as a guarnntce (extended or limited)that the on-iite wastewater system will fhuaicn properlyfor any given period of tune. Payment: Cash 0 Check 11 Money Or&:r(1# Ncaou:►t:S Date: Paid By. Received By:_ Account I- Invoice A