205 Whistling Ln HEAL�H a'FPARTMENT RELEASE ForOfficeUseOnlv
'CDP File Number 157560- 1
a..�,�s Davie County Health Department �.000-oo-oss-os
� y..�„
,:,�,� 210 Hospital Street County ID Number:
�`r° - � .'� P.O. Box 848 Evaluated For: HDR/VNWC
.,, „,..
'`��-a"` Mocksville NC 27028
� Phone:336-753-6780 Fax:336-753-1680 PERr.41T VALID 0 9 / 0 5 / a 0 1 9
UNTIL:
Applicant: Rick Clemmons Property Owner: Rick Clemmons
Address: 205 Whistling Lane Address: 205 Whistling Lane
C��Y: Mocksville Ci�Y: Mocksville
State2ip: NC 27028 State2ip: NC 27028
Phone#: �336)492-2218 Phone#: (336)492-2218
Property Location 8 Site Information
Address205 Whistling Lane Subdivision: Phase: Lot:
Road# Mocksville NC 27028
SINGLE FAMILY Tovrnship:
'StfUCtUfe: Oirections
#oi Bedrooms: #ot People: Davie Academy Rd.to Left on Mr.Henry Rd.go about 1/2 mile tum
right on Whistling Lane house at end
'Water Supply: N/A
Type ot Business:
Basement: �Yes�No
Total sq. Footage: No.Of Employees:
'Proposed Improvement:
Poot18X38
'Release Conditlons e.;
7:
This release in no way expresses or implies that the existing subsurface sewage treatment and disposal
system serving the site will continue to function for any period of time.
Applicant/Legal Reps.Signature Required? OYes ONo
ApplicanULegal Reps.Signature: 'Date: � �
"ISSUed By: 2�40-Nations,Robert 'Date of Issue: � 9 � � 5 � a 0 1 4
Authorized State Agent:
**Site P Ian/Drawing attached.**
C�Hand Drawing Olmport Drawing
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Phone:{326}-75a-s�aa � � z��:t33�-�58-1s8o
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I�Tame S`yst�m installcd L.rrzder: ' �pe Of�acility:— — -• � -
' . Date Syst�m Tnstnlle�(MonthlDatef`lear}: ���b � Number 4f�edrooms� ATuml�r t�f People: � � i
T�'�`he�acillty G�ixrentYy'Vacaut? �'es I�o If Y'es,For How Long?
�y Knotim pxobleras? Yes No YfY�es,E��plain: . .
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��,ease�i�i I�'I'he�ollo�sviau�Infarniatian A,bout',�he 1l�'��+�sciYity: � � .
Type OfFaci3�`ty:� ++- 1� G�� Ntuxt�er OPBeciroo�: Nu�zsber nfPzople 1 . I
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Pool Size: t� Gar e ize• pther. � I
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' , Fqr�nvironmen�al I�ealth Q£�i.ce�7se Orsly �
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Caznments: ' ' '
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. Bnvixo:uriental I3ealth Specialist 1�ate: �
. *1�`he.si�ning ofthz�form by the�rivirorimental l�calth Staff is in no yva�int�nded,nor shauld be tah,en,as a a arfinta� ;
� (e;ctend�d o �mxtedj t3�at the on-�ite�tasteti�tafsx systcm will�'unction properYy far any givezz period o£time_
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�'aymenC: C�h hec1C 'iv�oney # Amaunt:$ i Date:
�'aid By; IZeceivea By: '
Accotun##: ' Tn��ice�; � •
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ent VI�-���
�O�is j�' Environmental Health Section rf0�1�Z' ���
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C, ,�"�, 210 Hos ital Street r
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p�, ��;: Courier# : 09-40-06 = ; ,
Mocksville, NC 27028 +
Phone:(336)-753-6780 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: ��� ' C o.,ciK S Phone Number ��j ^� 1`^z � ZZ-� � (Home)
Mailing Address: L S� �k L.. (Work)
Email Address:
Detailed Directions To Site: �v �c c�.Nt E' i' • E'Hd� �`�( �
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Property Address:
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: Type Of Facility:
Date System Installed(Month/Date/Year): Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes No If Yes,For How Long?
Any Known Problems? Yes No If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: Number Of Bedrooms: Number of People
Pool Size: Garage Size: Other:
Requested By: Date Requested:
(Signature)
For Environmental Health Office Use,Only
Approved Disapproved
Comments:
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee
� (extended o imited)that the on-site wastewater system will function properly for any given period of time.
Payment: Cash heck Money Order # Amount:$ i� Date: l
Paid By: Received By:
Account#: �� � Invoice#:
. � ' • i� .
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� DAVIE COUNTY ENVIRONMENTAL HEALTH
. P.O.Box 848/210 Hospital Sh�eet
Mocksville,NC 27028 �
(336)751-8760 Fax#(336)751-8786
OPERATION PERMIT �
Account #: 990004497 Tax PIN/EH #: 5717-42-0141
Billed To: Rickie Clemmons Subdivision Info:
Reference Name: Location/Address: 205 Whistling Lane-27028
Proposed Facility: Residence Property Size: 5.8 Acres
ATC Number: 4809
�
� **NOTE**The issuance of this Operation Perinit shall indicate the system described on the ATC has been installed
�, in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"
�, \ but shall in N0 WAY be taken as a guarantee that the system wil�ction satisfactorily for any given period of
s time. `L,�� (c J l �h l _ U�',�
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S y s t e m T y p e: � S.T:M a n u f a c t u r e r T a n k D a t e � T a n l c S i z e
� Pump Tank Size
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System Installed By: <,��lLZ�d��C�Z' E.H. Specialisf: ��CI���U yD�: � O � �l ��
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� DAVIE COUI�TTY ENVIRONMENTAL HEALTH
P.O.Box 8481210 Hospital Street ��
Mocksville,NC 27028 )
(336)751-8760 Fax#(336)751-8786 a/Q�/��
�
AUTHOR.TZATION FOR WASTE�VATER SYSTENI CONSTRUCTION
Account #: 990004497 Tax PIN/EH#: 5717-42-0141
Billed To: Rickie Clemmons Subdivision Info:
Reference Name: ' Location/Address: 205 Whistling Lane-27028
Proposed Facility: Residence. Property Size: 5.8 Acres
ATC Number: 4809
Site Type: C9�IVew ORepair ❑Expansion
*'NOTE**This Authorization to Constnict(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building pernut(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 � #Bathrooms3•J #People�Basement❑ Basement plumbing❑
Non-Residential Specif cations: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
�
Lot Size � ��`f C/'� Type of Water Supply: ❑County/City ell ❑Community Well
• �GAL.Pum Tanl;, � ����GAL.
System Specifications: Design Wastewater Flow(GPD)�UQ Tank Size p _,�,,,,^,.,'
�r ►� ��
Trench Widtl�_ Max.Trench Depth�_ Rock Depth � r� Linear�'t. g��
Site Modifications/Conditions/Other: �� �t:�te� it� '��E� R��=�`� �5�n. �c��c��,;�' �
�:ccepted �y�tems mav �.I�rr �r, iirc:r W ��S���—�
Contact the Davie County Environmental�Iealth Section for final,i spection of this system between �"7
8:30-9:30a.m.on the da of installation. Tele ne# 336 751-8760. -to
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Env'�ronmental Healtfi Specialist Date: t ^ �3 —� U
� n/'F7Tl 71/(1(,/Rat�icar�� . � � '
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� Davie County Environmental Health
P.O.Box 848/210�Iospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
IMPROVEMENT PERMIT
Account #: 990004497 Tax PIN/EH#: 5717-42-0141
Billed To: Rickie Clemmons Subdivision Info:
Address: 5344 Halls Ferry Drive � Location/Address: 205 Whistling Lane-27028
City: Baton Rouge Property Size: 5.8 Acres
Reference Name:
Proposed Facility: Residence
**NOTE**This Improvement Pennit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to
revocation if site plans,plat or the intended use change.
Peimit Type: ew ❑Repair ❑Expansion Pemut Valid for: C�3�Years �No Expiration
Residential Specifications: #Bedrooms�#Bathrooms�•�#People � Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): �T�� Type of Water Supply: ❑County/City Cl�G�ell ❑Community Well
As staied in 15„ NCAC 1£3.�.1��� �
Site Modifications/Permit Conditions: 4v���Vy J��T��;:���4?����ti( )
System T e LTAR
Initial ec , �d . 1 �1 �h`S `�r
Re air c 1 (�. 1' "«
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Site Plan � � ��
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Environmental Health Specialist Date � � a�' '���
�.�.t t-06
O1/03/2008 ��p5.�F 57443116 'I'ESLA OFFS}30RE , C��^,02/002
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� � �,3 2���PLI ATIO FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
J A� ; ,l?aYie Cnunfy EatciconmentallIeatti►
\�t�, � P.O.Box 848l11U fIospitaf Street '��1 r�Li'�'
,,c�,`��F.� • • MocksvillqNC 27fl28._ •
� ,�;`�'G�'��:-,�'�..K�. � . � � � j336�752�91FaYj33b}7Si-E78b� _ � � � � -
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F,���`` �it.r';;...^.
1�� i
pplicatian Fnc Q Site Hvaluatiorilimprovemen2 Permit a Airthorizntioa To Cocatntct(ATC) �Both.
TypeofApp3icatian:�AtewSystcm DReyaitioExistingSystPm DExpansia✓Mati6caoonofExistingSystamarFaciFitg
•��IMPORTAN7��•THIS APPLICAT[ON CANNOT 6EPROC6SSGD UAtLF.SS ALL OF THE REQURLED
INRL)RMA'i'ION IS PRO�1tDEU.Refer ro the�TfORMATION BULLETIN Cm itMhactivns.
APPLICAhiI'�1�IFORMATIQhI
Name w be B�led__/I��� H, G-�f�Pn9�� Contaa Petsoa S%4M�
Bt7;ing Address 53 Sf .� s bR•�rZ ,r7,5'r/f£___ Home�orn ^ Z
CirylStaselZlP ��N o!/GE. 1//J�9N���usiness�one
Namc on PermiVATC ifD}8"eremtban Above
Maslssg Address CityfStatclZiP
PROPEItTY INFORMAT[ON 'Date Iiouse/Facili Comers Fla ed ��`��
NdtE: A survey ylat or altc ptan must accompairy this application. Inctu@cd:A Site Plan IIPlat(ro scale)
(Petmitisv�tiQfar64asntlssvritlrs�F�����CB��F�1
Owner's Neme �Gf'i�� rIr✓n EG/Tif�ET/f S; CL�g"1i�/-t Phone Nnmber t'ZS-�7lI/�J�/
Owner's Address�35��if�7fl ffiP.e ARivL City/5tate(Lip,G�tladiPUv6l, I 7oB/7
Pmpeity AddreSs 2� Lf1NIJfGn' L,a�✓f City 17Tae.�v///,E
LotSize S.8 Ac�PEs TaxPil�
SubdivuioaNam�e(if pticablal 5ectioalL.otN
Directions To Site: �Rom aq!//� C9a E.+)q �/��✓L��� o.✓To iP.��`�/�9 �4�
o ^� �2 M�/E Tn f�sr GRn*✓8 .v£ aJ��+.� /C�+T. /o•ci r�i��yv ,E.✓�
If t6eamwa-toaay af thef�tawiagquesiions is`�es;snp�iagdocv�atioa�stbeaitac�.
Are there any e�cisting wastewater syatems on tha site? D Yes�fto
Does tht siu contain jwisdictional wttlands? ❑Yu�u'No
A.re fhe;a ar+y easemer�ts or'ri�x-of-�vays o�t5e site? CJYas jS(Na
Is tAe site subject to approval by m�othu public agrn�y? OYa�7t3o
Wi(Iwestewaurothnthandomesacsewa eBegenerated2 QYes o
���av�€��.i.���c���.a�
�People #Bcdtt+oms �Bathmoms 3. 5 £r3r,dea'IY�h.�lNhir}pns+}�,�1'cr f}Nts
Basement QYes o BasementPlumbin : OYes o
�Norr-xEsm�rrcE r�r.�.our rxs Bvx s�.ow
�ry�e of�ac�ny��s �m�s�,���gz�r$naa� �r�� ..
#sirdcs #Commoaes u showcrs N EJria�is -
Estimated Watec Usage(gatluns per day) (Attach documentatiou ofsimiiar faciliry water consumption)
FOODSERVICE ONLY: #3eats .
Tyj125}SSeInIPQ11C3Itd: ��DIIYCDI��D3I LIATCCjf2i� DIE[1qY8IlYC .OAIICIAAdYP DOIfICr •
L�''�:.,"S::;.;,t3'TY.%..:�Cc::r;�;Cd��k.ar: �.�',-.0�'e;! �..xe°:s^>g�'.':t: u C;;::z;a,i.;1\:.;
Do you a»tieipate additions or expansions of the fazility this System is intendsd to serve?0 Yes "j�No ��\
ffye;whattype7 ' �.V/�
(�J
?his is{o certifg that the infocmatinn provided an ihit applicafloais ttue and coueet to the best of my iuwveladge. I undentettd \\
t6at any pem�it(s)or ATC(S)issued hereafter nre subject ro suspeasion m revocation if the sitc is eltcrcd,the mtended use ��
� c}ncsges.w ifshe infom�atioa submitted in dus eppticatiou is falsi5ed or r��d I hereby gra,n rip�,t nfentry ta fhe Authori�rd �
Representativ�of the Devie County Heetth Depamnent to comduct necessery inspections to determine compliana with applitabie
laws and niles. I understand that I am responsible for the proper idenUfication�nd labeling of property liaes and comus and
locsting -s '�' t,�usw'faeiTiry lveation.prvposcd weil tocation and the 3oeati�n of mry ethcramcnities.
�~" Site Revisit Charge
Propenq oti 's or mmer's iegaf repraemativt signature
Dak(s):
d( vj Zq�� CliemNotification Date:
Dete EIiS:
Sign givcn OYes DNo Account R 1�+
Revised 11/06 Invoice#
_ _ _ _____ _ _ _ __ .
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• • DAVIE COUNTY HEALTH DEPARTMENT
� ' � Environmental Health Section
Soil/Site Evaluation
APP���ffPQ��'��1 Tax PIN/EH #: 57�� �Y INFORMATION
Billed To: Rickie Clemmons Subdivision Info:
Reference Name: Location/Address: 205 Whistling Lane-27028
Proposed Facility: Residence Property Size: 5.8 Acres Date Evaluated: � "' �� G�
���
1 � ��
Water Supply: • On-Site Well Community Publ
Evaluation By: Auger Boring Pit �, . C . ��
r� , , ,
FACTORS 1 2 3 4 5 6 7
Landsca e position S .
Slope % � � �
HORIZON I DEPTH - G- <i - �i O' O- 5� O— �- �
Texture grou . L 5 L S L 5 L 'L L.
Consistence ' r ' r � ' � . `
Structure '
C�.,.....k. w�.�.,. C:J�'-' .,,.,.t
Mineralo t- � - f� i y7 E�p ��p �,
HORIZON II DEPTH - � -/.l� - � , � 7- l
Texture rou • � t' ��� G $(� G ��L G
Consistence ,'! " • :� 7 � '`/1't �.Q.�•�✓' :Y'
. JtIL1Ctl1I�C Y! �� , r4 f5 � � �iy Y . �� L i�`+y
Mineralo -X � G t< < '7�� �. t /�l� •rt�
HORIZON III DEPTH i 1 - , - � ( - 1.( a— (LO 1 -
Texture rou --'L S L L 5 G L�
Consistence ' �-' � . .T •, ��,
(' I�f t.�+
Structure C . � � , J. �V ��- t- ka �CY r,�
Mineralo ' N,�'� �.. , ` � p C !' Sl��
HOR�ZON IV DEPTH � �• ��
Texture rou �,
Consistence
S tructure •
r
Mineralo
SOIL WETNESS �-
RESTRICTIVE HORIZON . *] " c �1�," ,:u�
SAPROLITE '� ' �� '� �c. , ;fr S « �Inn.-.,� u /k.
CLASSIFICATION 5 5 5
LONG-TERM ACCEPTANCE RATE 17'� �• �7 5 . / ./ "—
SITE CLASSIFICATION: �� EVALUATION BY: ' � GL� �
LONG-TERM ACCEPTANCE R.ATE: v� 17� �' j� OTHER(S)PRESENT: �O Ib''S�P�S .
REMARKS: -Gc� �. IG� � � �� •i. �..�
LEGEND �
T,an s ��e Position �
�� . O
R-Ridge S -Shoulder L-Linear slope FS -Foot slope .•N-Nose slope , ^ { S ��
CC -Concave slope CV -Convex slope T-Terrace FP-Flood plain H-Head slope A ,
Texture . � �.a✓
S -Sand LS -Loamy sand SL-Sandy loam ,L-Loam SI-Silt !'�',ll�l��
SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam �O�+` �;� �,`�2
SC-Sandy clay SIC-Silty clay C -Clay J .�. �`
CONSISTENC'E_ ��` �
��
VFR-Very friable FR-Friable FI-Firm VFI-Very firm � EFI-Extremely firm
�
NS -Non sticky SS -Slighdy sticky S -S[icky VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
Str� t�r
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic �
Mineral�gv "
1:1,2:1,Mixed
lYQtr�
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-tenn acceptance rate-gal/day/ft2 DC:HT�()5/hS (RPvicPsil
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NO SCALE
JACK A. SEAFpRD VICINITY MAP
o D.B. 140, PC. 702
6 —_�� 1/4' EXISD"G
- // /�__ ` — IRON
CL
pMp EXIT —
��-- SEE DE' EA� 12164—� -- WHISTLING LANE -7-
— —
141. 491T -
- ___WHISTUNG LANE
Q i �i NG 30' EASEMENT / - --— -'�
SEE D.B. 141, '
ISTING 30' /
b / NEW 30' A Ly SEE D.B. 141. PPG. 49f
1
N�'Z SELL EASEMENT Tv SE /
iJANE N00 44 . , AS OF NOV-27-2007 ooN ,�
ROBERTA . A 83, pG• 8 /
1).13s RET"" .'� JANE PG• 4a'r',e
I owl I OF°TM,s ; . ; E g,'�A , 4
Oww D.8
191
/
I NEW 10' WATER
VERA GAIL KOONTZ IJAMES EASEMENT
D.B. 183. PG. 851 ► AS F NOV-27-2007
• i
/
/
UNE BEARING DISTANCE
CORNER �d L1 N 29'07'29' E 45.25
NEW1p �9j X16'E / L2 N 33'25.12' E 57.77
IRON ' r L3 N 38'20'56' E 68.83
L4 N 38'02'52' E 38.59
e L5 N 47'45'06' E 21.90
+/- LOCATION OF 4i� �,R1, L6 N 59'04'47' E 37.86
FUTURE HOUSE 3.0 OB D.BA. •IANE KOON?' L7 N 21'27'44' E 27.21
B• >83, PC, 8 4 'SELL
W AREA= .5.855 Ar, NOTES:
205 Whistling Lane
1. TOTAL TRACTS= 1
Z m tiw 2. TOTAL AC.= 5.855 AC.
~� 3. NO NCGS GRID MONUMENT WITHIN 2000 FT.
ti 4. X= UNMARKED POINT OF NEW EASEMENTS.
5. PROPERTY IS WITHIN A WS—IV WATERSHED.
15700 oN VT
12o N �"44'Z3• y 99.66
@P•44, V
N e 442. y PLAT MAP:
RON - - - R OBER TA JANE KO ONT Z SELL
OWNER DEVELOPER
/ ROBERTA J. K. SELL
296 MR. HENRY RD.
MOCKSVILLE, N.C. 27028
l ERNEST/ •. (336) 492-7123 KOONTJR.
D.B.D98, PG, >4 CALAHALN TOWNSHIP
4
/ DAVIE COUNTY, NORTH CAROLINA
/ DATE: NOV-27-2007
/ TAX MAP REF.: K-2, P/0 58.01
SURVEYED BY:
TUTTEROW SURVEYING COMPANY
I, Grady L Tutterow, certify that this plat was drawn 107 NORTH SALISBURY STREET
under my supervision from an actual survey made �����""''��., MOCKSVILLE, NC 27028
under my supervision (deed deecri tion recorded in .•�,�N..CA& �, (336) 751-5616
Book ; Page . etc.) l other);that the �•Q +• SS!
boundaries not surveyed are dearly indicated as drawn :,�•;•'Q,OF� O
from information found in PL Book Page 1 = 100
that the ratio of precision is calculated as 1 L+20.000 ; z = SEAL =
that this plat was prepared in accordance with G.S. L_2527 i - 100 50 0 100 200 300
47-30 as amended. Witness my original signature. r Q
registration um ran I is Z1 day of I 1'sy'Yd �La�'Q•' SCALE IN FEET
O' y
~••'SUR•••''
r�
eyor r�Hi�r�����``�,`� FILE NAME: COORD NAME: DRAWING NUMBER:
(Seal or Stam Registration Number SELLSJ KMABEIII-39
20607-36