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165 Our Place Davie County, NC Tax Parcel Report 01 $ Friday, September 23, 201E f11 e-' 1$871893 --- ---- 128 ,�—T----- `'�„ 18 79 142 1859 1847 -• '`� -r r- �¢ I/ 165 t 2 01 - 1815 130 f 1781 162. tr�'//�,rr _..._.__.h.__x�__�_._ ._ ._.�_l _.�..._.._._...._.-.......................... WARNING: THIS IS NOT A SURVEY Parcel Infonnation Parcel Number: G700000031 Township: Shady Grove NCPIN Number: 5769589393 Municipality: Account Number: - 82514315 Census Tract: 37059-804 Listed Owner 1: EDDINGER RICHARD M Voting Precinct: WEST SHADY GROVE Mailing Address 1: 165 OUR PL Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A,R-20 State: NC Zoning Overlay: Zip Code: 27028-7270 Voluntary Ag.District: No Legal Description: 8.714 AC CORNATZER ROAD P/O LOT 3 Fire Response District: CORNATZER-DULIN Assessed Acreage: 8.69 Elementary School Zone: CORNATZER Deed Date: 4/1999 Middle School Zone: WILLIAM ELLIS Deed Book/Page: 002100913 Soil Types: SeB,PcB2,PcC2,EnB Plat Book: 0004 Flood Zone: Plat Page: 160 Watershed Overlay: DAVIE COUNTY Building Value: 370740.00 Outbuilding 8r Extra 36560.00 Freatures Value: Land Value: 64590.00 Total Market Value: 471890.00 Total Assessed Value: 471890.00 All data Is provided 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 or fitness 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 NC or arising out of the use or Inability to use the GIS data provided by this website. . Ti• .5 Nd 4421cs •- DAME COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST APPLICATION IP/ATC OSWW REPAIR Name I e4j1Vtq0- Telephone Number Address �� i• Mailing Address (if different from above) Email Address: Subdivision Name Lot# Dir ctions -24L !1/ r � Date System Installed Name System Installed Under Type Facility Number Bedrooms_ Number People Served Type Water Supply Specific Problem Occurring 14 a Date Requested "�V` Info Taken By THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED FROM THIS APPLICATION. U} 15 i I-p aF- C�` �k -( o (.a-(-Z. Q M✓V 4 9 Signature of owner or Authorized Agent Initial Fee Date REHS Revisit Charge Date Reason Revised 2-2011 /3 �3 j 1a -1 , .1(I YG77 r •� :' ) ) 1975 J4"A I-, jr 25 93 41 3198 •--�-�.._� ---�lL -�./ f.✓ �:, �1 d� 4149 165 �' 181 x191 1 1'b2 �\ � W All data is provided as is without warranty or guarantee of any kind either expressed or implied Including but not limited to the Implied o warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the County of U 1y ' Davie,North Carolina,its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out Pri nted:Apr 17, 2014 5 of the use or inability to use the GIS data provided by this website. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section U P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 C� Account #: 989900440 Tax PIN/EH#: 5769-68-2385.0001E Billed To: Richard Eddinger Subdivision Info: 1(t Reference Name: Greg Nifong Location/Address: matzead-27028 Pro osed Facility: Property Size: ATC Number: 3078 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 WASTEWATE O STR CTION IS VALI FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: C3, CERTIFICATE OF C MPLETION **NOTE** The issuan a of this Certifi ate of Completion shall indi a the system described on I ovement/Operation Permit has been in lled in compli nce with Article 11 of G.S.C apter 130A,Section.1900"Sew a Treatment and Disposal Sy tems,"but shall in NO WAY be taken aY_g tee that t 1 function atisfactorily for any given peri of time. 1 C1% a 21 c c, a cti 76 � 1 ` C- uVf a Septic System Environmental Health Specialist's Signature:. Date: DCHD 05/99(Revised) /! Q�y !� A �P DAVIE COUNTY ENVIRONMENTAL HEALTH • ' P.O.Box 848/210 Hospita.l Street • . Mocksville,NC 27028 (336)751-8760 Fax#(33.6)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 989900440 Tax PIN/EH#: 5769-68-2385.0001E Billed:To: Richard Eddinger Subdivision Info: Reference Name: Greg Nifong Location/Address: Cornatzer Road-27028 Proposed Facility: Property Size: ATC Number: 3078 Site Type: QNew ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specifications: #Bedrooms #Bathrooms -3 #People BasementErl asement plumbing.- Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size��.e j Type of Water Supply: ounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) Tank Size 0 rcbAL.Pyimp Tank&OOGAL. Trench Width 3G 1 Max.Trench Depth (> Rock Depth Linear Ft. U 00 Site Modifications/Conditions)1Other: As t1ated Irl 15h NOV' +h n 4(369(8) Contact the Davie County Environmental Health Section for final inspection of this system between 8:30-9:30a.m.on the day of installation. Telephone#(336)751-8760. Ilk pflr a r.r �< i (Min io �"�"`�� ,r► 8�r _ _�';� '- Lid� ,�, -y. Environmental He t pecialist Date: D �� DCHD 11106(Revised) Apr 09 08 10:55a._ DME. ENTERPRI§ES p.2 DAVIE COUNTY HEALTH DEPARTMENT > ' Environmental Health Section �d J P.O:Boa 848/210 Hospital Street � G ? •_ MocksviUe,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900440 Tax PIN/EH#: 5769-68-2385.0001E Bwed.To...RichaM.Eddinger Subdivision Info Reference Name: Greg Nifong Location/Address: Cornatzer Road-27028 Proposed Facility: Property Size: ATC.Number. . 3078 "NOTE"*This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank-systern or any wastewater system. An AUTHORIZATION FOR WASTEWATER-SYSTE'4 CONSTRUCTION-m-ust-be obtained from this... Department prior to the constructionfinstallation of a system or the issuance ofa building.permit.(in..compliance with Article I I ofG.S:Chapter 130A;Wastewater Systems,Section.19(10-Sewage Treatment.and.Disposal.Systems). THIS PERMIT 19 SUBJECT TO REVOCATION-EF SITE PLANS.ORTHE.INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SE -THIS.FERMIT BEFORE INSTALLING SYSTEM. Residential-Specification:.Building Type. #People #Bedrooms #Baths Dishwasher:.Garbage.Disposal:;e Washing Machine: Basement w/Plumbingi❑ Basement/No'Plumbing:' Commercial Specification: Facility Type #/People #People/Shift #Seats -Industrial Waste.--O Lot Size IA _ Type Water Supply ''6L Design Wastewater Flow(GPD) �� Site: New�Repairn System Specifications: Tank Size A GAL. 'Pump Tank ~GAL: Trench WidthRock-Depth Unear.Ft. � Other Required Site Modifications/Conditions: EMPROVEMENIT/OPERATION(PERMIT-LAYOUT- APPROVED EFFLUENT FILTER..RISER(S)IF b-"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 pm.on the day of installation. Telephone#is(336)751-8760.**** Environmental Health Speciarst's Signature: DCHD 05/99(Revised) - 'DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street �- - Mocksville,NC 27028 (336)751-8760 /�j� �l f'yt E IMPROVEMENT/OPERATION PERMIT ,3y Account #: 989900440 Tax PIN/EH#: 5769-68-2385.0001E Billed To: Richard Eddinger Subdivision Info: Reference Name: Greg Nifong Location/Address: Comatzer Road-27028 Proposed Facility: Property Size: ATC Number: 3078 **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 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 Dishwasher: Garbage Disposal:000' Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size &-.JC Type Water Supply Design Wastewater Flow(GPD) 7 U� Site: NewETOOO'Repair❑ System Specifications: Tank Size An GAEL. Pump Tank GAL. Trench Widthc.?6 r Rock Depth /Q y Linear Ft.,d Other: c1G,C�„„ Required Site Modifications/Conditions: IMPROVEMENT/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 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** Environmental Health Specialist's Signature: 4 vz7e Date: DCHD 05/99(Revised) APPI-I('A110N FOR SITE EVALUATION/IMPROVEMENT PERMIT& to, ' Q, Davie County Health Department a a r /�, EnvironmentaiNeaith SmWon P.O. Box 848/210 Hospital street FEB I ? 1999 ti �J Mocksville, NC 27028 • r /�) (336)751-8760 ENVIRONMENTALH LTH t*tZ34PORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL Q " INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for �,instructions. 2I1. Name to be Billed C 4A RD C— D'DIiNr-GeContact Person KRIS+;Ur Dn4cr-' Nailing Address sol 00 S&A Home Phone 38(P--8e3Q 3(o 0 city/state/ZIPW/CC Business Phone 2. Name on Permit/ASC if Different than n Nailing Address city/State/Sip 3. Application For: *-Site Evaluation 0 Improvement Permit/ATC 0 Both 4. system to service: 01House ❑ Mobile Home 0 Business 0 n s ry ❑ Other s. If Residence: # People _119 # Bedrooms # Bathrooms a 8'Dishrasher �Oarbage Disposal ig Bashing Machine t] Basement/Plumbing 0 Basement/No Plumbing 6. If Business/Indus rtry/other: Specify type # People # Sims i Commodes # Shovers # Urinals i Nater Coolers IF FOODSERVICE: # Seats Estimated Nater Usage (gallons per day) 7. Type of water supply: 0 County/City 0 Well 0 Community 0 e. Do you anticipate additions or expansions of the facility this system is intended to serve? fes 0 No If yes,what type? &")r!k S '02 ***IMPORTANT"**CLIENTS AfUST COAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Pxoperty Dimensions: �Q / WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tar,Office PIN: # $f7& 1 - -,238 Jr '1-o CaatZrsr- Property Address: Road Name edu A+7 EKyA54 *Ke 4 tlle& C'�16�6 City/Zip e ENS R(VC E If in a Subdivision provide information,as7�ICA s:Name: G�t 1�oc� GDp Section: _� Block: Date Property Flagged: E 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 1,also,understand that I ars responsible for all charges fxcrured from this application. i,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by--e A lop 1 E7 scigp to conduct all testing procedures as necessary to determine the site eh. DATE h2a l SIGNATU LE' THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimenslou structures, setbacks, and septic locations). -- Account No. Revised DCHD(07/98) Invoice No. S', erev� i � ✓o)C �— &q&&, '.�� DAVIE COUNTY HEALTH DEPARTMENT N _ Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME DATE EVALUATED13 PROPOSED FACILITY PROPERTY SIZE SUBDIVISION ROAD NAME �p�✓lZ.d'�Po� Water Supply: On-Site Well �� Community Public Evaluation By: Auger Boring LZ Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position 2— Slope Slo e% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupU Consistence r Structure &h 'L /l 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: EVALUATION BY: LONG-TERM ACCEPTANCE RATE:_ OTHER(S)PRESENT: REMARKS: &Z' 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 ois VFR-Very friable FR-Friable FI-Firm VFI-Very fine 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 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(oi-vo) ■■■■■■■■■■■■■■■s■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■■■e■■■eee.■■e■e■■■■ ■■■■■■■■■■■■■■■■■e■eee■■ee■■e■■■�se■■■ee■■es■■■■eee■■■■e■■■ee■■e■ ■■■■■■■■■■■■■e■e■■■■■■■■■■■■eee■■■■■■ee■■■■■■■■■■■e■■eee■■■■■■■ee■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■se�■■■■■■■e■■■■■■■■■■■■■■■■■■ee■■■■ ■■■■■■■■■■■■■■e■■■e■■■■e■■■■■■■■■■■■■■e■ee■ee■■■eee■■■e■■■■■■■ee■■ ■■e■e■■■■■■■■■eee■■ees■■■■e■■■■■■■eye■■eee■e■ee■■■■■■■■■■■e■■■■■■■ ■■■e■■■�!.ecce■■■�_c■■■■■■■■■e■■�■e �■■■e■■■■■■■■e■■■■■■■■■■■■■■■ ■■■■■■■ee■■■■■eee■■■■■::■s■■■�:�■■s■��:�■■s:.■■■■■■e■■e■■■■■e■■■■■ ■■s■■■■■■e■■ee■■e■■■ese■■e■■e■■■■■■■■■■se■■■■■■■eee■e■■■■■■■■ee■■■ ■■■■■■e■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■■epi■■■■■■■■■■■■■■■ MEMNONiiiiiiiiiiiiMEMNONiiiiiiMEMNONMEM: ■■■■■eee■■■■■■■■■■■■■■■■■■■■■■e■■■■■■eee■■■■■■■■■■■■eeeee�e■■■■■e■ ■e■■■■■ecce■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■►�■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■see■■■■■■■ee■■■■■■■■■■■■■■■■eee■■■■■■■ ■eee■■■■■■■■■■ecce■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■eeef■■■■■■fl■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■�I■■iG!!■Ilii■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■eee■e■■■■■■■■■■■■�i■e��neue■■ ■■■■■■e■■■s■■■■■■■eee■■■■■■■■■■■ ■■■e■■■e■■■■■■■■■■e■■■■�■e■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■eee■■e■■■■■ee■a■■�■■e■■■■ee■■■■eee■■■■eee■■■■■■■eery■■s■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■a■■■■■■e■■■■■■■■■■■■■e■■■■■■■eee■■►■■■es■■ ■■■■■■e■■■■■■se■■■■eee■■■■■■■■■■�i■■■■■�i ■■■■■■e■■■ee■■■■■■��■■■■■■ ■■■■eee■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■e■■■■■ee■■■■�■■■■■ ■■■■■■e■■■■■■■■■■■■■■■■■■■e■eee■■■■■a■■■■■■■■■■■■■■■■■■■■■■■■e■■■■ ■e■■■e■■ee■■■■eee■eee■■■■■■■■■■■■■■■■■■ee■e■■■■■■■e■■ee■■■■e►�■■■e■ ■■■■e■■■■■■■e■■eee■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ee■■■■■e■e■■■�■■■■ 4 7 o DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751.8760 March 17, 1999 Richard Eddinger Re: Greg W.Nifong 5200 S. Main St. Winston-Salem,NC 27127 Re: 2 Site Evaluations/Cornatzer Road Tax Office PIN: #5769-68-2385 10 Acres Each Site Dear Client(s): As requested, a representative from this office visited the aforementioned sites on March 11, 1999. Based upon the information provided on the Applications for Site Evaluations and after evaluations were completed on the sites, each site was found to be provisionally suitable for the installation of a modified, oversized on-site sewage system Before Improvement Permit(s)Muthorization(s) to Construct can be issued the appropriate application(s)must be filled out and the house/mobile home location staked on each site. If you have any questions,please feel free to contact this office. Sincerely, Robert B. Hall,Jr., R.S. Environmental Health Specialist RH/wd Enclosure(s) cc: Zoning Office J. f • ; APPLICATION FOR SITE EVALUATION/IMPROVEMEN-f PERMIT&ATC • Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Contact Person ;J� (��u Mailing Address .S Home Phone City/State/ZIP S Business Phone `� �J p26 2. Name on Permit/ATC if Different than Above Mailing Address .5200 '-SZUfV, ►MA( S City/state/Zip lll� S 3. Application For: Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People '_ # Bedrooms _q # Bathrooms XDishwasher ❑ Garbage Disposal Washing Machine Basement/Plumbing ❑ Basement/No Plumbing 6. ' If Business/Industry/Other: Specify type '\ # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City / \ Well ❑ Community 8, Do you anticipate additions or expansions of the facility this system is intended to serve? Ayes ❑No If yes,what type? ***IMPORTANT***CLIENTS MUSTCOMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. 4 Property Dimensions: y RITE DIRECTIONS from Mocksville)to PROPERTY: Tax Office PIN: # C� Q �p p 3 (,1� E l(/ Property Address: Road Name city/zip ' If in a Subdivision provide information,as follows: Name: Section: Block: Lot: Date Property Flagged: 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 am responsible for all charges incurred from this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department 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 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). Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. Revised DCHD(07/99) Invoice No.