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139 Indian Hills RdDDII SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department OCT 1 3 2006 Environmental Health Section P.O. Box 848/210 Hospital Street �NIRONMENTAEHEALTN Mocksville, NC 27028 DAVIE uNN (336)751-8760/ Fax (336)751-8786 Application For: Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both ***IMPORTANT"* THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed i _ Contact Person Billing Address Home Phone 33 C- 9I ,-f— 99 C f, City/State/ZIP _ C 1 Business Phone .336 'O 'i Name on Permit/ATC if'Different than Above Mailing Address PROPERTY INFORMATION NOTE: A survey;plat or site plan must accompany this application. (Permit is�lid for 60 months i s' plan o expiration wi c mplete plat.) Street Address :. IUL�S i City l/Qn e Tax PIN# %g-, d �f Subdivision Name S ction/Lot# Lot Size Directions/To Site: %n c� �i?L P, Jehcl — Ze;w7 e /i Date House/Facility Corners Flagged /Il p " bel{ d,Je If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes ENo Does the site contain jurisdictional wetlands? ❑Yes E�lo Are there any easements or right-of-ways on the site? ❑Yes EfNo Is the site subject to approval by another public agency? ❑Yes E rNo Will wastewater other than domestic sewage be generated? ❑Yes 2No IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms t # Bathrooms . Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes CRo Basement Plumbing: ❑Yes (Il-P�o IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: Peonventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: (�ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes U11 fly If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspectionsjv determine compliance with applicable laws and rules on the above described property located in Davie County and owned by m l% 4 L-Url -.J ttA.'_1 Prop rty owner's or owner's lega r presentative signature 696 l ate " Site Revisit Charge Date(s): Client Notification Date: EHS: Sign given L9'Yes ❑No Account # Revised 2/06 Invoice # c avtY �. .� c n 7� s + �;. a A� g` ♦� yr � •,,�h, 1 Y�P b� F� t✓R Y y� n .:• K Y ''e s t"WrI t tea" I'lle �_,,,'n K '� ,e r �.� '° � ��s�. � :." y� " �.� Y r sip �i k �� �= •� OFF- � rsg m 4 �L � e � x 'a o�, ��4•�� � ^•ice L.C! ;"' � err v' es / �lT mmg �.( y , lid IISp l W wr: S� wF 1 r. it `x A f t4 d TOM, r i u. i '��, � � .,r� '+i^ rv" r wl, �M�R ����� ��✓j� �/�-a�hvo`f`�/ .q'� � t,+ ^�„`,�LLq°�y u � ��.��Y_, ../T' "�',"`�l k J± .r..85 k.Af'..�^ +' �}•" � �lnT?i „�% Y*K,:- �. y",.y"l;':�t � •� ' Ulf; W Y�" JF°, i � k�j y I s� �sl�°�• +?k e.y •1�. y�.`-. S a,Y ."'" `Y` r,' 'Sn �' 4""�V.-`W... :__I'� k`. :'�" �s3 ..a z�c sem....�.u -m:-•."D.-. �. ,^'�' w:r_-'. , ._t m 1-W . ao 3754) INDIA H LLS RD n 5asp 40 co A) 9' 3753 B 774 � 267 alo9 was (144A) .� , . p us _ ti? n C roz N 1376 4336 17.6�6A 3585 J �_ — 0 � I f m APPLICANT INFORMATION Account #: 990004142 Billed To: Ronald Jones Reference Name: Proposed Facility: Residence Water Supply Evaluation By: On -Site Well Auger Boring DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5778-09-4336.03 Subdivision Info: Jones Estate Lot # 3 Location/Address: Indian Hills Drive -27006 Property Size: see map Date Evaluated: Community Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND EVALUATION BY: OTHER(S) PRESENT: 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 SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 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 Naim 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 05/05 (Revised) 7Evaluation/improvement R SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Application For: Permit ❑ Authorization To Construct(ATC) ❑ Both ***IMPORTANT'"* THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed CYC► ' , ") Contact Person Billing Address E ,U 261 J Z VZ Home Phone 3 City/State/ZIP C •y ' ; Business Phone 3 5 V a Name on Permit/ATC if'Different than Above Mailing Address PROPERTY INFORMATION NOTE: A surveyplat or site plan must accompany this application. (Permit islid for60 months wit�fe plan expiration wi c mplete plat.) Street Address -�Nr" 11 r-lh/ 16�/�s �. ��IONdS rAtIN City f, V't2m Tax PIN# ;y 9 2S C' Subdivision Name / Sectio/n/Lot# Lot Size Directions/To Site: 1W c? r i?L' )t!_)t L-;:41 o/�-r s(L ��/�' • i l h Date House/Facility Corners Flagged 1. P " 'b, 1 5-t},t; e If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑ Yes QNo Does the site contain jurisdictional wetlands? ❑Yes 0to Are there any easements or right-of-ways on the site? ❑Yes ffNo Is the site subject to approval by another public agency? ❑Yes EINo Will wastewater othet than domestic sewage be generated? ❑Yes 0No IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes Wo"" Basement Plumbing: ❑Yes RX6 IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: Peonventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 26ounty/City Water ❑ New Well []Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? Z Q -.-- This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspection$ tQ determine co lliance with applicable laws and rules on the above described property located in Davie County and owned by 11 V 4 EV H --J dA)F ZZ Prop rty owner's or owner's legat'r presentative signature ate Site Revisit Charge Date(s): Client Notification Date: EHS: Sign given LYYes ❑No Account # 7 l v _ Revised 2/06 Invoice # A, °" "*• k F i3i°� �w$ ..r i?. >✓:.'� <4e rc' y w1hd £ .i t ,y k . V We -TS9'•. vt.'i-Yc u'. � ^; w,.•t.�4a�C r KW t y 4-{ riJ Y' h y wy`'2'�y� "� y�� 'fir r s: � c;�»•s,�5+ � m r e, o•'# J' "v�,wa>sx� ct�!'Y��, � � � y ''u �a w� a '" ." •. r � r� �3•r.J x i �" d��Y�»� t?°" �'° '.{. i'.a`�, •A"y, t vts r . _ '. XF'� w. 3d'y' gS�a '�?'' I ,`.F , *-' .. �,... � �.`'.i*�t ��yy�et - � f� �s� �. [i. •�� r'+1'Cs�r ....�itt '�`' N A �, �A'a35p,'(-"S~� 3 �.wv, 5. .y Xksx ' "`S''` ,%A NM�da�a �,' Od oo i t Lb i I r. F , yx D , - Derr �... �';��`�`,:ltr ,��'',• r t `��t , — IT�„,� f�.r r :D�� � ���'r iv� 'i� i$:�?AB'" :.,.. '! w-'�.:? .•��. b5.d`,ry CtC, f�"� � � i �� k� ,.�a '�; . n fix' �. .w'Y,�> ��• � � � � '. .fir P1' I 11 APPLICANT INFORMATION Account #: 990004142 Billed To: Ronald Jones Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5778-09-4336.04 Subdivision Info: Jones Estate Lot # 4 Location/Address: Indian Hills Drive -27006 Property Size: see map Date Evaluated: On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE ' MQist VFR Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 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 LYQts� 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 05105 (Revised) I, George Robert Stone, certify that this plot was drawn under my supervislon from on actual survey made under my supervision (deed descr 1ption recorded in Book "_, Page * , etc.) ( other ); that the boundaries not surveyed are clearly indicated as drawn from information found in Book , Page ' that the ratio of precision as calculated Is 1/10,000; that this plat was prepared in accordance with G.S. 4T-30 as amended. Witness my original signature, registration number and seal this 9 day of October A D 2006 • RB 321 Q 295 Seal or Stamp George R. Stone Surveyor �N CAROB L 3162 20 tcESS��� ��'9 Registration Number SEAL ' L-3162 W T*I : 7 off: 2 � ROBERT I, George Robert Stone, Professional Land Surveyor, L-316-I2�certify to certo one of the following as indicated thus, ® or E ; a. That this plat is of a survey that creates a subdivision of land within the area of a county or municipality that has an ordinance that regulates parcels of land; E] b. That this plat is of a survey that is located in such portion of a county or municipality that is unregulated as to on ordinance that regulates parcels of land; ❑ C. That this plat is of a survey of an existing parcel or parcels of land; Od. That this plat is of a survey of another category, such as the recombination of existing parcels, a court-ordered survey or other exception to the definition of subdivision; ❑ e. That the information available to this surveyor is such that I am unable to make a determination to the best of my professional ability as to provisions contained in (a) through (d) above. George R. Stone Prof i-ol Land Surveyor, L-3162 STATE OF NORTH CAROLINA COUNTY OF DAVIE I,Review Officer of Davie County. certify that the map or plat to which this certification Is affixed meets all statutory requirements for recording. Review Officer: Date: "NO APPROVAL REQUIRED BY THE COUNTY PLANNING DEPARTMENT" Planning Director Date EIP - Existing Iron Pipe PROPERTY UNE CALL TABLE COURSE BEARING DISTANCE COURSE L-1 S 85°57' 10"E 297.00' L-10 L-2 S 02°10'45"E 290.54' L-11 L-3 S 02°10'45"E 332.12' L-12 L-4 S 02°10'45"E 458.38' L-13 L-5 0� L-6 S 02"10'45"E S 02°10'45"E 393.00' 391.50' L-14 L-15 L-7 N 89037'35"W 172.54' L-16 L-8 N 89044'03"W 128.82' L-17 L-9 N 02000'07"W 391.50' 416.22' I, George Robert Stone, Professional Land Surveyor, L-316-I2�certify to certo one of the following as indicated thus, ® or E ; a. That this plat is of a survey that creates a subdivision of land within the area of a county or municipality that has an ordinance that regulates parcels of land; E] b. That this plat is of a survey that is located in such portion of a county or municipality that is unregulated as to on ordinance that regulates parcels of land; ❑ C. That this plat is of a survey of an existing parcel or parcels of land; Od. That this plat is of a survey of another category, such as the recombination of existing parcels, a court-ordered survey or other exception to the definition of subdivision; ❑ e. That the information available to this surveyor is such that I am unable to make a determination to the best of my professional ability as to provisions contained in (a) through (d) above. George R. Stone Prof i-ol Land Surveyor, L-3162 STATE OF NORTH CAROLINA COUNTY OF DAVIE I,Review Officer of Davie County. certify that the map or plat to which this certification Is affixed meets all statutory requirements for recording. Review Officer: Date: "NO APPROVAL REQUIRED BY THE COUNTY PLANNING DEPARTMENT" Planning Director Date Tax Lot 44 EIP - Existing Iron Pipe BoC - Back of Curb TIE LINE CALL TABLE PP - Power Pole BEARING DISTANCE CM - Concrete Monument MH - Man Hole IRS - Iron Rebar Set n/f Charles L. Lon P/L - Property Line COURSE BEARING DISTANCE N 02000'07"W 393.00' PB - Plat Book CMP - Corrugated Metal Pipe RB - Record Book N 02000'07"W 458.37' T-1 S 85056'59"E 362.43' N 02000'07'W 332.13' T-2 S 70048'23"E 2796.01' S 02000'07"E 309.58' T-3 S 34011'01 "E 820.01' N 89037'58"W 296.50' T-4 N 86°51'53"W 416.22' N 89038'38"W 297.52' T-5 N 85052'41 "W 25.16' N 89"39'10"W 298.94' T-6 S 87047'52"W 42.44' N 89039'46"W 300.16' T-7 N 89038'11 7"W 164.93' Tax Lot 44 EIP - Existing Iron Pipe BoC - Back of Curb EIR - Existing Iron Rebor PP - Power Pole Tax Map 1-7 LP - Light Pole CM - Concrete Monument MH - Man Hole IRS - Iron Rebar Set n/f Charles L. Lon P/L - Property Line P/0 - Part of C/A - Controlled Access DB - Deed Book DB 83 O PG 225 PB - Plat Book CMP - Corrugated Metal Pipe RB - Record Book CPP _ Corrugated Plastic Pipe DB 100 O PG 3 -F- 100 Year Flood Boundary CB - Catch Basin -0- Overhead Utilities -S- Sewer Line T -Bar w/cap F / -9 WV - Water Volve L-10 by Flat Iron B� NMP - Nonmonumented Point Shed CL - Center Line RRS - Rail Road Spike EP - Edge of Pavement CTV - Coble Television Pedestal r -------% :Proposed: EfB - Electric Transformer Box Shed �I CO - Sanitary Sewer Clean Out (nts) - Not to Scale House 10 x 70 SE - 10' x 70' Sight Easement 120 0 120 240 360 ` --- --j _[f r_______ t :Proposed: % House A Denotes Nonmonumented Points Defining Center Line h ' NMP in dip Sycamore Tree Pond O I_j i 2.700 Acres +/- 2.700 Acres +/- '1 Proposed 30' Access Easement See Easement Call Table Id - - �-E-7 --E-8 T-Bar�w/cap F by 1&1/2" LIP w/f ttin i L-6 IRS L Tax Lot p Tax Me 1-755.01 }^ Tax aTax 1-7 n/f Her on W. Stevens I� n/f Ellis Kent Walser RB 637 PG 988 .I RB 322 O PG 845 1" OP Fnd Mgle Iron Fnd NAD 83 0 00 R/W - Right -of -Way LEGEND FC - Face of Curb EIP - Existing Iron Pipe BoC - Back of Curb EIR - Existing Iron Rebor PP - Power Pole P - Post LP - Light Pole CM - Concrete Monument MH - Man Hole IRS - Iron Rebar Set CH - Chord Distance P/L - Property Line P/0 - Part of C/A - Controlled Access DB - Deed Book CP - Concrete Pipe PB - Plat Book CMP - Corrugated Metal Pipe RB - Record Book CPP _ Corrugated Plastic Pipe PG - Page -F- 100 Year Flood Boundary CB - Catch Basin -0- Overhead Utilities -S- Sewer Line -X- Fence WM - Water Meter Fnd - Found WV - Water Volve n/f - Now or Formerly BM - Bench Mork NMP - Nonmonumented Point TBM - Temporary Bench Mark CL - Center Line RRS - Rail Road Spike EP - Edge of Pavement CTV - Coble Television Pedestal TP - Telephone Pedestal EfB - Electric Transformer Box -W- Water Line CO - Sanitary Sewer Clean Out (nts) - Not to Scale CF: Combined Factor 10 x 70 SE - 10' x 70' Sight Easement 120 0 120 240 360 GRAPHIC SCALE - FEET Tax Lot 57 Tax Map 1-7 n/f Darlene S. Stroud DB 178 O PG 130 "1 (we) hereby understand that this plat is approved as exempt from the Subdivision Ordinance of Davie County. This is a family subdivision and is for the exclusive purpose of conveying land among family members within the third degree of lineal kinship. These lots/tracts shall not be used for the purpose of sale or building development, either now or in the future, except for those family members. Additional approvals may be required by Davie County or its successor agency before any subsequent sale or building development may occur." Owner(s) Date Owner(s) Date Owner(s) Dote Owner(s) Date I further acknowledge that my family members who will be conveyed the newly created family lots are: 1. Sherry J. Jaycocks co-owner/sister Lot #1 2. Mark Douglas Jones co-owner/brother Lot #1 3. Donna Kay Seaford co-owner/sister Lot #1 4. Ronald Gray Jones co-owner/brother Lot #1 5. Mark Douglas Jones co-owner/brother Lot #2 6. Ronald Gray Jones co-owner/brother Lot #3 7. Donna Kay Seaford co-owner/sister Lot#4 8. Sherry J. Jaycocks co-owner/sister Lot 5 "T Pond 1 Shed 3.135 Acres r' ed, Filed for registration at o' clock 20 and recorded M In Plat Book , Page . M. Brent Shoal, Register of Deeds Filing Fee Paid TWINPORT AZ MK N: 241139.002 m E: 477806.803 m by CALL TABLE FOR CENTER LINE OF PROPOSED 30' ACCESS EASEMENT DEPUTY -ASS I STANT CF: 0.99990724 Indian Hills Road S.R. 1613 60' Public R/W 20'+/- Pavement 1 Of COURSE BEARING DISTANCE - Contact Address: Sherry J. Jaycocks E-1 S 85°57' 10"E RRS Fnd O CL 165.49' Tie Line c E-2 N 85°57'10"W 131.51' Tie Line r )v E-3 S 04024'1 7"W 314.47' E-4 S 89037'58"E 151.94' ' NPORT E-5 S 02010'45"E 317.10' N: 241066 5.627 m N: 241 E-6 S 02°10'45"E 458.39' E: 478471.139 m E-7 S 02010'45"E 393.00' CF: 0.99990535 E-8 S 89039'46"E 15.01' rie Line 411 E-9 N 89039'46"W 285.14' Tie Line N A Denotes Nonmonumented Points Defining Center Line h ' of Proposed 30' Access Easement 820 <\a G�� `o><el N iRS1L 2IRS 1L 2 Total (279.56') T -Bar w/cap o RRS Fnd O CL +\- Fnd in Line v I 1O I i (Proposed%a House % 2.037 Acres 3 L-1 Total Ji O _ 9_Orivewav� s + Shed PHouse o +/- 2.265 Acres N. t _j Shed v o IT ° n c Building + y oX I 4 - - - - Building r Garage s, -ravel Drive •-E-6- - - - - - - - - - - - - ------------E-5---- - - - - -- -- �__- ' - / 4 - - - - Gravel/Dirt Form Road IRS L-3 IRS\`\ f- L-2 Total - - Gravel/Dirt Form Road 1 �\ I J__- 820 RRS Fnd O CL +\- rT-5 (260 50') T -Bar w/cop a RRS Fnd O CL +\- \ Fnd in Line r Indian Hills Road Tax Lot 55 Of^ <t S.R. 1613 Tax Ma1-7n/f Danny Burt Walser c 60' Public R/W 20'+/- Pavement RB 322 O PG 848 �� Tax Lot 54 Tax Map 1-7 PK -Nail Fnd O Intersection n/f Charles W. Bailey of SR 1611 & SR 1613 DB 109 O PG 306 I (we) hereby certify that I am (we are) the owners) of the property described hereon, which is located in the subdivision Jurisdiction of Davie County and that I hereby adopt this subdivision plan with my free consent, established minimum building setback lines and dedicate all streets, alleys, walks, parks and other sites and easements to public or private use as noted. Data ornw(s) osis owner(s) Date Owner(s) Date Owner(a) Owners: Contact Address: Sherry J. Jaycocks 168 Cedar Hill Lane Mark Douglas Jones Advance, NC 27006 Donna Kay Seaford Ronald Gray Jones Site Plan for: Sherry J. Jaycocks, Mark Douglas Jones, Donna Kay Seaford, & Ronald Gray Jones, Property Tax Lot 56, Tax Map 1-7, Record Book 321 O Page 295 Total Area Tax Lot 56, Tax Map 1-7: 12.834 Acres +/- (Inclusive of area within S.R. 1613 R/W) Area computations by coordinate geometry SCALE TOWNSHIP COUNTY STATE DATE 1" = 120' Fulton Davie North Carolina 10-09-2006 Sum Stone Land Surveying Company JOB No. SC,DBA George Robert Stone, PLS L-3162 17106S MAPPED: 113 Drum Lane Phone (336) 998-4733 kW NO. GRS Mocksville, N.C. 27028 17106S