208 Shoffner Ln (2) Davie County,NC Tax Parcel Report 0�� �, Thursday, October 6, 2016
( � �
�.�}�-� �
_._.�_ rf --'""--„ _ I
r
. �tr �� I
��
� �� ��
~1t,_—�-- �_—�
� ;� ,,,,� I
:.°�� '`�,,
� 2G8 �
� • �`�
� � , �a' ' ��
IC° ` `� � � .
� �,�; ,
��� � :_-h. �
� � }r `�.
i ,........._
�� �~ I
�._...�.._.._....�__ ' � ., ��.,` �
� ���� �1�i �;�---._�, �e�... I
ti.. ,�a � �-,,,,� �:;� r�'` �
�..
-,it �,;w., , r` I
K �e..-•`` �:,,
�:� �i i
--�-�.,�„_159 j ;,, _` f �
� f:
j �� 153�.� __....,�
(4�� � ���`"^��'t y��(] �
----- —��-��` ---------- ��-------�S�L------��— � - — —�
WARNING: THIS IS NOT A SURVEY
- , ,..., . .. , .. .. . �._ t-- . _..� . �_ .., ..,- -- -
' ; . ParcelInformation _ :; ,
Parcel Number: C20000001301A Township: Clarksville
NCPIN Number: 5802687800 Municipality:
Account Number: 65605000 Census Tract: 37059-801
Listed Owner 1: SHOFFNER LARRY D Voting Precinct: CLARKSVILLE
Mailing Address 1: 208 SHOFFNER LANE Planning Jurisdiction: Davie County
City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A
State: NC Zoning Overlay:
Zip Code: 27028-5945 Voluntary Ag.District: No
Legal Description: 4.15 AC OFF SHOFFNER RD Fire Response District: SHEFFIELD-CALAHALN
Assessed Acreage: 4.09 Elementary School Zone: WILLIAM R DAVIE
Deed Date: 2/1999 Middle School Zone: NORTH DAVIE
Deed Book/Page: 002090645 Soil Types: MnC2,MdD,ChA
Plat Book: Flood Zone:
Plat Page: Watershed Overlay: DAVIE COUNTY
Building Value: 14890.00 Outbuilding&Extra 0.00
Freatures Value:
Land Value: 21450.00 Total Market Value: 36340.00
Total Assessed Value: 36340.00
�,V� All data I�provided as Is without warranty or guanntea o(any klnd elther axpressed or Implied Including but not Iimited to the
9�"'�F Davie County� Impliad warranties of inerchantability or fltness for a particular use.All usen oT Davie County'a GIS webalte ehall hold harmless the
County of Davia,North Carotina,Its agents,consulWnts,contractors or employees from any and ail clalms or causes of action dua to
n0�,N,�'� NC or arlsing out oi the use or Ina6ility to use the GIS dah provided by thfs website.�
, ,
, . . ,.
1��.,�k!�.�� ��..;t� P•+`..w '�r .ii�s'.�.,.tx�.ti:'li�til.���Z�1wY�f.���it'' r.,y:`3�n � 'a,�+Y: a'lw�e•�a a �.�5�,�� �t�.���rtr . °w ,�..';�'d-'i x at -;4'T '��',�fc' "`..� `f:•'i1��., '"�c.
. ' . . - . . . . . � �%�d
�� aU'rxOx�zA'rIorr NO: O 8 4 Z DAVIE COUNTY HEALTH DEPARTMENT �
. ��=' �� Environmental Health Section PROPERTY INFORMATION
Permittee�s P.O:Box 848
Name: "= . Mocksville,NC 27028 ' Subdivision Name: '
� ,,r / Phone#:704-634-8760
Directions�to property: l�� ��,!r �f r%,�� Section: Lot:
AUTHORIZATION FOR Gt�Q d 4 D /�Al
�
SYSTEM CO STRUCTION Tax Office PIN:# � - -
` �/ ('� '
Road Name:,�f9 0`]7'?`1 C r"'��p: ;% r� �'
**NOTE**This Authorization for Wastewater System Conshuction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance,of any Building Pemuts..This Form/Authorization Number should be presented,to the Davie County Building Inspections
Office wheri applying for Building Pernuts.
(In compliance with Article 11 of G.S.'Chapter 130A,Wastewater Systems,Section:1900 Sewage Treatment and Disposal Systems)
��� � �/ ��'�'`� ***NOTICE***TIIIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
^J5�-'SG,'�f.�-��a� ��J �S"`� "1- IS VALID FOR A PERIOD OF FIVE YEARS.
�•.—�
ENVIRONMENTAL HEALTH SPECIALIST :, DATE�. , ,
� �.a,•d..r4' Yw µ!}�p 'irrrr '1-13•.�d�:«}�A,y�...r�(�:�.'� �k•`�'.SsF 7s�'�'C�`h�Y��j.�^'�{'4 5���}1.tt5w�w.a�„�:;.Y")h,�Y�s. q�It+�.:'t.•y.,�� r'4" w1 +.��;u' lt W.r��r.C: �r �i�, !"" .',�,.h�.y.✓"l���i= =�V 7i.;y'
�� ��r
. �.,. '�.� ,.t5� } . , . . . . . , 'y� .
� � `, '��"""' �DAVIE COUNTY HEALTH DEPA{�T NT
� f��r .� .. . . � � , .
"- �A�:,,�� . � IMPROVEMENT AND APERATIOI�PE�� PROPERTY INFORMATION
Pe�rtt�cs,�s �.,�� ,,� �
' Nan�:'�¢ " Subdivision Name:
, � - ,. :
��" --' " �:�.��'- �: .., r:.� -� � � . . . r :.r:..�� : . . . , :,_ .
Directions fo"property; �,.°`.� ;�t�-� f' :.� ��,�� SecUon: Lof:
< IlVIPROVEMENT C�,.r��1 C'tc?�C7� I:�:f��
� _ PERMIT Tax Office PIN:#
,'�
Road Name:��➢n �}�t r'-',��p .�r-(�.��
**NOTE**This Iinprovement Pernut DOES NOT authorize the construction or installatiQn of a septic tanlc system or any wastewater system.An
AU'I'HORIZATION FOR WASTEWATER SYSTEM CONSTRUC'TION must be obtained from this Department prior to the .
construction/installa6on of a system or the issuance of a building pernut.
(In compliance with Article 11'of G.S.Chapter 130A;Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) '
.__.. ; �
j i � , ' ***NOTICE***THIS PERMTT IS SUBJECT TO REVOCATION IF SITE
_...';.',.�'� �,,� ��=':a4�,a,.„,t.'�`���,.,�' � PLANS OR THE IN'fENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST' DATE ISS SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING TI�SYSTEM.
RESIDENTIAL SPECIFICAT'ION:BUILDING TYPE�� #BEDROOMS �#BATHS caZ #OCCUPANfS�GARBAGE DISPOSAL:Yes or No
COMMERCIAL'SPECIFICAITON: FACILTfY TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY ��' DESIGN WASTEWATER FLOW(GPD)� NEW SITE //' _ REPAIIt SITE
SYSTEM SPECIFICATIONS: TANK SIZF✓ ��D� GAL. PUMP TANK GAL. TRENCH WIDTH �r ROCK DEP'TH,�<.,�� LINEAR Ff. �C7a�
' OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: . !
IMPROVEMENT PERMIT LAYOUT
, �,
/�
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-930 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(704)634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
� .
�
_ r
AUT'HORIZATION NO.���OPERATION PERMIT BY: 1'—�'T DATE: �
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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 T!-IE SYSTEM WII.L FUNCTION SATISFACTORILY FOR ANY GNEN PERIOD OF TIME.
DCHD OS/96(Revised)
I �
-_.
• , APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERML &ATC
� ''' � Davie County Health Department l
, { - � - � � � � o��
Environmental Health Section
• P o. sox g4g APR 2 3
� Mocksville,Nc 2�o2s �997
� � (704) 634-8760:
! �
� �'�'�'�IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
; .
� 1. Name to be Billed�G��� �/ �/!f�T�n L�� Contact Person �^ �v
Mailing Address �'�� �/f?7'�hT(a� Home Phone �c� Cl����' ��4
City/State/Zip �U"��� '�0� /�L° •�. �1�7� Business Phone �f� �'� �`�����CJ
- 2. Name on PermidATC if Different than Above ti' O �
• Mailing Address �� �107�' `P �. uj� C City/State/Zip �CJ G�� di��P ,2�� , (�'��
3. Application For: [ ] Site Evaluation [ ]Improvement Permit&ATC [�(�Both
� 4. System to Serve: [ ]House [{�'1�Iobile Home [ ]Business [ ]Industry [ ]Other
� 5. If Residence: #People_� #Bedrooms� #Bathrooms� [•]Dishwasher[ ]Garbage Disposal
, [t�Washing Machine [ ]BasementlPlumbing [ ]Basement/No Plumbing �
6. If Business/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 [y]h�ell [ ]Community
I 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [�To
� If yes,what type?
' EZTHER A PLAT OR SZTE P1.ttN
PROPERTY INFORMATION REQUIRED:***IMPORTANT***�'�OF THE PROPERTY MUST BE
; y SUBMITTED WITH T APPLICATION.
. Property Dimensions: � '7` � �WRITE DIRECTIONS(from�Vlocksville)TO PROPERTY:
(�l�D� � !oe�/V L�e �� �n .�-�be,efy��iu��! �C'�d.
i Tax Office PIN: # Ca DDD�D
t Property Address: Road Name�J�vTT n l°'Q �l!� � �lh�i�z°S�Pff on �7F�l,��.�f t°�,'� ��iurr� f�.
� City/Zip /�OGk$t//�!�°►//�� �d� ;��� /1 'o j1 th h �L��r�-f'/"5 a n ��
; p ; �1� R��f�sh�'���,� �I
If in Subdivision rovide information,as follows:
Name: ;�r�Qr�.�jo� �e�l-�'�" ��17�T�/�P,� dP.
�
Section: Lot#: ; ��a p�%v e D Yl �7°"�7�
�"
' 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
Represe tative of the D vi Co nt Health Department to enter upon above described property located in Davie County and owned
: by � `�� ��������/ t onduct all testing procedures as necessary to determine the site suitability.
, DATE �������(I SIGNATURE �
'
Revised DCHD(06-96)
1 1tt l $E USEb OIt�b1tt1W I NC� 1 OUR S Z TE PLsIN:
THIS �l ZEA l� J �' ,
- �
; �
� �
�
, �
1 � � ' .
� � a
Y
^ �
,V
_ . ;;�-,�- � � DAVIE COUNTY HEALTH DEPARTMENT
r ' � • . Environmental Health Section SECTION LOT
• SoiUSite Evaluation
APPLICANT'S NAME �� ^ DATE EVALUATED �� —
�� ,
PROPOSED FACILITY ��� PROPERTY SIZE o2 L
SUBDIVISION � ROAD NAME _�/�n���r -C 11�^t
Water Supply: On-Site Well � Community Public ,
Evaluation By: Auger Boring q� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition L L- - L
Slo e% Z.
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH � �!- �. d r—
Texture rou L
Consistence
Swcture i S �c /
Mineralo /,� ,%
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE c
SITE CLASSIFICATION: � EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Tenace 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
CON5ISTENCE
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
Mineraloav
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-gaUday/ft2
DCHD(O1-90)
■�■��■�■■■��■s■■�■■������■■����■■■���■���■�������■■��■■�■■■■�o�■W■
■�■����■�����■■�■■������■■��■■�■■���■���■■������■■���■�■■■����■��■
■�■�■�■■���■�■■�■■��■��■■���■�■■ ■■���■■���■���■■���■�■■■������n
■■■���■■���■�■■�■■��■��■■��■■■■■�i��■■■■■��■■�■�■■��■■�■■■���■��■■
■■■�■�■■��■■■■��■■��■���■■■■■■■����■■■■■■��■■■■■■���■�■■�����■��■■
■■■�■■■■��■����■■■�■■�■������■■■■■■■�■■■��■■■�■■■■�����■��■■■■■��■
■■■�■■■■��■■���■■��■■�■���■■■■■��■���■■■��■■■■■■■��■��■���■■■■���■
■■■■■■■��■�����■■�■■■■���e■■�■■��■■��■■��■■■�■■■�■���■■�■■■■■■���■
■■�■�■■�■■■■��■■��■■�■■■�■■■����■■■■�����■���■����■��■��■■■■■�■��■
■���■■■�■■■�■�■■��■■�����■■■���■■■■��■��■■■��■■���■��■����■■����■■
■���■■��������■■�■■■■■����■��■�■ ■��■�■■■■�■■�■��■��■�■��������■■
■��■�■��■■����■��e■��■��■■■����■���■��■■■��■■��■■■�■■�■■����■�■■■
■������■■■��■■■■■■■�����■■��■�■■■���■■■■■���■����■��■■�■�����■■■�■
■�■■�■�■■■���■■�■■��■���■��■■■■■■��■■■■■■�e■■��■■��■■��■����■■■■�■
■���■�■■�����■■�■■��■������■■■■■■���■■■■s�■■o�■■���■■���������■■�■
■■■���■■��■■�■��■�����■■■��■■■■��■■■■�■■��■■�■■■■��■■�■��■■■■����■
■�■���■■��■■■■��������■■��■■�����■■■������������������■��■■■�����■
■■���■■���■v�■�■��■■�■■���■■�����■■��■��■■■��■���■■��■��■■����■�■■
■■�■��■��■■■■��■��■■��■��■■����■�■��■��■■��■■��■■■�■■�■■■���■�■■■
■��■■■■�■■■���■■��■■�■■��■■����■ ■■■��■■■�■■��■■■��■■■■■���■■■■■■
■■■■■■��■■■�■�■■�■■■�■��■■■������■�■���■■��■■�■■■■�■■■�■■���■■�■■■
s■�■■■��■■����■������■��■■■�����■■�■�■■■■��■■�■■■��■■��■���■■■�■�■
■�■■�■��■■����■■■■■��■��■■■�■�■■■��■■■■■■��■■�■■■���■��■��■■■■�■�■
■�������■■��■�■■�■■�■���s■�■■■■����■■■■■■��■■�■■■■�■■��■��■■■■���■
■�■■�s��■■��■�■��■■■����■■�■■■■����■■■■■■�■■��■■■��■■�e���■■■■�■�■
■�■■�■��■■��■�■��������■■■�■■���■�■■������■■■■■■���■��■��■■■■��■�■
■�■■���■■■��■■■��������■■■�■■����■■������■■■■■■�����■■��■■■■��■�■
e�■����■■��■�■■s■■��■��■■��■■■■■ ■■■�■��■■��■■��■■�����■■■■��o�■■
■�■���■■���■�■��■������■■��■■■■■��■■��■��■■��■���■■��■��■�����■��■
■�■����■���■�■��■�����■■■�■■��■��■■���■o�■■��■���■■��■��■■������■■
■�■���■■��■■■■��■��■�■■■��■■����■■■�����■■■�■■���■■�■■■■■■���■��■■
■■��■�■■�s■��■�■■�■■��■■�■■■�����■■�����■■��■■��■■��■■�■■■���■�■■■
■■����■■��■■�■��■�■■■■■■��■■�■��■■���■�■■■��■��■■■��■��■■����■■■■■
■����■■���■■■■�■��■■�■■■�■■�����■■■����■■��■■■�■■��■■■�■����■��■■■
■■�■�■■�■■■o��■■��■■�■■�■■■�■��■ ■�■�s■■��■■�■■■��■■�■■�o■■■■�■�■
■■�■■■■�■■■�■�■■��■■■■■�■■■�■■■■�i��■■■■■��■■�■■■�e■■��■��■■■��e�■
■■�■■■■�■�■�■�■■�■■■■■��■■�■■■■■■��■■■■■■�■■■�■■■��■■�■����es■�■�■
■■�■■■■�������■■�■■■■■���■�■■■■����■■■■■����■■■■������■�■�����■■�e
■■■se■��■■��e�■■■■■■■���■��■■■■■����■■■■������■■����o■■o■�����■■o■
■�■■�■��■■������■■��■��■���■■■■■■�■�■■■��■■������■����■■■■���v■��■
■������■■��■■■■�■�����■■■�■�■�■■�■■��■■��■■�����■■■���■■■■��o���■■
■���o�����■■■■■�■■�■��■■■�■■����■■■�����■■��■����■�����■■���■■�■■■
�■�■�■■�■����■��■■■�■�■■���������s■��■■■�■��■■�■■�■■s■■■�
■���■■ ■■■■�■ ■■�■■■ ■■�■�■ ■�■■�■ ■�■�■■ ■■■�■■ ■��■■■
■■■��■■���■����■��■■�■■��■■�■■���..--------
_-��-�.���■��■���■■��■��■■■■■■■�■
■��������■■�■�■����■■■■�c:;�::��■■���■■■■��i���■■■�o����■�e���■�■■a■
■■�■�����■■�■�■■�■���■��■�i��■■■■■�■■■■■���i■■������■■����■■■■���■�s
■■�■■■��■■■���■■■■■����■■�i��■■■■��■■■�■■���■��■���■■■��■��■■■��■��■
■�������■■■�■s■�����■��■■�i��■■■■�■��■■■���i���■������■■■■��s���■��■
■�■����s■■��■■■��������■■�i��■■■■��e��■■�■�����■������■■■■������■��■
�0���...�V�1������■
�����������������L������ ������,������������������������
■������■■■�■■■■����■■�■■��■■■■■���■�■�■■���■■�o����■■■■��■■�■■�■■
■�■■e��■■��■o■■�■�■■■■■■■�■■����■■■�����■■��■���■■���■■■■■���■��■■
■�■����■■�■■■■��■�■■�■■■��■■����■■■����■■���■■���■��■■��■ae��■��■■
■�■�������■■■■�������■■■�����■�■■���■■�■■v��■■■�■■��■■�������■■��■■
■�■�■�■■��■■�■�■■�■■�■■■�i�����■■■�■■�■■■a�■■��■■��■■�e■��v�■■��■■
■�����■���■■��s■��■■�■■��ri■�■■�■���■■■��■r��■■����o�■���■���■■��■�■
■■�■�■■��■■���■■�■■��■��■��■■■■■■��■■�■����■�■■���■■�����■■■■����■
■��■■■��������■■■■�����■■�r�■��■■�■��■■��■���■�������■■���■■�����■
■��■�■��■■������■■��■���■�Y■■�■■ ■■����■■■�����■■■����■■■����■��■
■�■��■��■■�■�■■�■■����■■��■■��■��■■��■��■�a�■■������■■����������■■
■���■��■■����■■■■■�■���■�■■■���■■■■����■■■����■■���■■■■■�����■��■■
■���■�■■■������■■�■�a��■�■■■���■■■�v�■■■■■��■�■■■��■■�■■����■■��■■
■■��t�■■��■■a��■■�■■■■���■■����■■■�■��■■■��■��■■o��■■�■■��■■■■■■■■
■�■�■�■■���■�■�■�����■■�■■■����■■■��■:�■■���■■■��t■■■�■���■■■■��■■
■■�■��■�■■■������■■■�■��■■e■■■■■■��■�i�■�■■■��■■�����■■o���■■■��e■
■■�■■■■�■■■�■�■��■■�■■��■■�■■■�■�■■■����■■��■����■��■��■■■■■��■�■
■��■�■��■■���■■�■■■�■��■■��■■�■■ ■■��■��■■��■���■■�■■�■■■■■�����■
■�■■�■��■■�■■■■��■�■■��■■��■■�■��■■����■■■�����■■■��■■■■■�■■��■��■
■��■■■�■■����■■�■■���■■■�����■■���■��■���■�■■���■■��■��■■��a��■�■■
■�■���■■��■■����■��■��■■�■■����■■�o�■■�■■��■■�■�■��■■��■�����■�■■■
■�■���■■��■■�■�■��■■�■■��■■����■■���■�■■■���■�■■��■■■�������■■�■■■
■■■���■■��■�■■�■��■■■■■��■��■■��■��■■��■■�■■��■■���■��■���■�■■���■
■�■�������■�■�■�����■■�����■■■����■■■�■��■■����■��■��■��■■■■■■�■�■
■���■■������■�■���■�■����■�■■■■��■■��■��■■��■�������■��■■■■■����■
■■���■��■■����■■�■�����■■���■�■■ ■■�■����■�■���■■■��■■■■��■�����■
■��■�■�■■■�■�■■�■■��■���■��■■�■��■■��■��■■��■■��■■�■■■�■■■�������■
■�■■�■�■■��■�■■�■��■■�■■��■■�■���■■����■■■��■�■����■■����■����■��■
■�■■���■■�■■■■��■■■■��■■�■■��■���■■�■������■��■■■���■■■■��■����■■■
■�■�■�����■■■■��■�■■���■�s■��s�■■���■■■■■�■■■�■■■t■■��■���■■■■■■■■
■■■�■�■■��■■■■�■��■■�■■�■■■�■■■■���■■��■��■■��■���■■����■■■��■■■�■
■■���■■����■■�■■��■■■■��■■��■�■■■��■■■■���■����■t����■s��■■■�■■■�■
■��■�■��■■��■��■�■■�■���■��■■■■��■■�����■���■���■��■■�■■■�■�����■
■��■■■��■���■■■��■��■��■■�■����■ ■�����■■��■���■���■■�a��������■■
■�■����■���■�■��■��■��■■��■����■■■■�■��■■��■��■■■��■■��■�����■��■■
� " . STATEMENT
^. `�AV�COUNTY HEALTH DEPART7VIENT
ENVIRONMENTAL HEALTH SEGTION
� * 210 HOSPITAL STREET
' P.O.BOX 848
MOCKSVILLE,NORTH CAROLINA 27028
(704)634-8760
Payment Due Upon Receipt of Ihis Bill.
Detach and Mail a Copy of Bill with your Check. .
Your cancel[ed check is your receipt.
n;�y i�, i�9�
L�rry :'�ho�fner
�C�� Shoffner Ln.
i�lack sv i 11 e, i�dC 270�g
6��-1�-97 5i�;e ��r�lu.�tion 3 �et�oit/R7G ,���:a44� �1���.��.� �
. , 1-
_ � �
� �
_ . �
_ �, i �
� $
�
�' ��--
�
� �s����E rst�� n;�t� —���w��.�o=