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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 1 . . � . , • .. � • . / � � . . � . ���,�.��� . - . . � � . � ����- , �avYe �oun. �eal_�h De ar#�x�ex�t�%�� , � � ,' p .�i��?�� � Er��viro�xrie�.ta� �ie�J.�. �ec�,on.. �D�Z��' � � � +� . �'.O. Bax s�8 , �a�`�� ' � � �. 210 Hospital 5t�reet ���,�,��. � Courier#:09-��-06 �<;�.;1 iYlocksc�lie,�V'C `�7028 Phone:{326}-75a-s�aa � � z��:t33�-�58-1s8o • �J,���71A.L'� 1��1�Y7'�lA'✓��L'JAl�.I.CICw�r11Q1,'{ � . (Chec.�One) RepXac�mex�t �e�,aodeliug �ecnn�nection . ' I�ame: t � �.uh .� Phone 11u�nbr,r .7i.�h '^� 1�. +�--�� � (�-iame) C • Mailing Address• L ��- , ' � (War�s} l , Email Address' neta,iledDireckians To Si.te: ��l�t ���� ,��13�.�.. �__ �C.G[ `�!7 �" . e/�di � � . � Kr�". i �l C(. �- 1 �. �� L l �J1�L� LV l�t ! �!l �. n �,� �i. � � ' — "O�� �� , . PYOp�Xty,t��T.3S: . . Flease Ffll ba T�e Fo�.ti�sving In�arinati��n�bout'rhe E.Kt�'T�11rG]E'aca�.rty: r� � � ' � 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: . . . - � � . . � ' � ' - �t ��,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 l�L.�'M.]�i L�_ , . 1 Pool Size: t� Gar e ize• pther. � I � RequestedBq: Dataficquested�_ ,�`'� � 1� � I • ( re} • . � ' , Fqr�nvironmen�al I�ealth Q£�i.ce�7se Orsly � . �PPa"oV�d bxsapproved � . . Caznments: ' ' ' , � • � . ' � , . 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_ � �'aymenC: C�h hec1C 'iv�oney # Amaunt:$ i Date: �'aid By; IZeceivea By: ' Accotun##: ' Tn��ice�; � • • �� � //1 GrG:J�.:a rr► , ,„-� � •� ,..._.. .... . - ,.....,, G� �j(,pDTj.� � � /�•�• ..f�~��..�1'� _.�`'��`��:.__./�, �-�``"'--~ -w`."`._.�'-.`_'�.�..,�,_; ��KS�/o�' N � fy �"w..`"" . � �~�•� � I r. , ���.�..-.....�^^.....--•� � �rw�r+�� . . � • ����y�'• �� � .��f}��,,,J,.-�.� . ��.�Tt�.�.-� =-;�--• ' S�'��� r---- . -��.�%:;f.-''' "' ,� �� __ . .i ��l�r� 1 •:! " �n1NurSt y�/ELL µrY�%i..!J. "�� ���------- -, ,,- cx, � �`''� o � R � �� h�ous� �' E�5 � 30� � . l'1 . .....r.--� �� , '�.,,___._.:� w � . jr,__.��____----=......_..._.___..f .P�o l � � , _ � J� � .. � � � � � + � � � . !� '. � � � I • �. , . � � � i . � �i - � �Qc . i � � � �: � . � � �' � '`r�.. . ' - � � � ' �i. . �_._-_.. .....__.., . .. �0 3 . � • �� � ' � ' .� . � . � , �° . ; - _ �/Vm7" �a .�c�-�� . . . . ..___��...�.�.-_ _ __��_ ---- _ � . � � ' . ��'�-c�o �-- . . . � . �� � � � ���� Dav�e County Health Departm ent VI�-��� �O�is j�' Environmental Health Section rf0�1�Z' ��� .. . �g 't �` �.,,,;: M �"�a P.O. Box 848 �� „ �� :�.: , C, ,�"�, 210 Hos ital Street r P : s!�'�� _: 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� �`�( � � C�� ( , � � �Z � �— �w�v (.v G► � s��-�i e a. �. d 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� . � • � � 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�',� � , ��� � �, �� � � aOU '�� ` 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 . (�" �-� �� � System Installed By: <,��lLZ�d��C�Z' E.H. Specialisf: ��CI���U yD�: � O � �l �� � . �" ���, � v � r�z� �3� 0 � ` +S� , � � �u� �[ �,� ` I u��'"h � ���` - , �---------_--.� � , � , ��� �� r.�.� �- , � � �..� -- � ,, a � I yhv-�,J �j� �9 .-�- r ,JLL�� �l ���� Q J•� � N G � � Y� �� , � 3u U � � . � ��� , . J'_ • . � 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 .. �1�1.1M�Q iNl u s ` ' �`� Ul s�PCY I-T' �O W �/'{a'�t✓ �i�/�d`�j'/ �1 �+Y�,�•'�'� �� � � . . ��� � ��C �t t�v n 7 SC��j Qd i-���.I �4 r2��c-,r '� �''/ ;•{`" ��` _ . / � � '_ ,����:� `a..� b.z 0� ' i � .�j--s� . �`,tclur�cD b��UW i � ` ` � � �s�y� � (�� /5�a-'X3���,�rs /. �go ' w � C�� �S S� k3 Li�.� � , � l�� (!� S�lasti bo�c ����r°' ' �' � �� � b411 V�u►� �o �a� n���..r � o � f� � a & � u < <�.e -� low pQ-- a �, �" 1 n �1 a l-�' 1 ��L Ih n �'a . to' �,:� Env'�ronmental Healtfi Specialist Date: t ^ �3 —� U � n/'F7Tl 71/(1(,/Rat�icar�� . � � ' � . � , � 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' "« ; � - 7 Site Plan � � �� 3/ � J � ��� �C , �``, ' i,, /v'°�th H��''r � , ' � � , i , �� , •� � �.$o ' fi o� �� .`�_ �v `��, �� � � h �� , �' ryz��`' �i� �; _- Environmental Health Specialist Date � � a�' '��� �.�.t t-06 O1/03/2008 ��p5.�F 57443116 'I'ESLA OFFS}30RE , C��^,02/002 . V �• \J � ` • .��y � � �,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� _ � � � � - ,�` „+ ,.. .... _ 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# _ _ _ _____ _ _ _ __ . _ __ _ _____ GoMAPS -.Davie County NC Public Access Page 1 of 1 . . . Davie County, NC - GIS/Mapping System ��r I Q 536 � i { ,�� II �� � � Click Here To Start Uuer QUick Se�rch;�Cc,unty ID c � �`I.;+�' `'+ - � ��='� �Sctiu� La}�er. � Use�'+�a,er 7r,as GIS �tr t'��' �; � � � � �', PARCELS i.�Aap Tip=:.�+railahl�l t�iap L�yers � Result� � II __ e..� ..r.._.�. __ .__ a.. _�_�.r_._ . 7_�w7 _._.,. .._.....,i , ._._ . .... . ..._ ..._. ._... . �� 7 � . S �— — — � . � 1 J i � �i �--- —�—�— � � �' �� — -- S'184'd �8��?!"I� _ , , J'� �' 1� t l _}'_ _ _ �1 F! �i 'P.i . 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Davie County, NC - GIS/Mapping System Q�°"r�` Click Here To Start Ouer Quick Se�r^th:{CoU�ty ID c , _. ��.� �� , n� �"' �` � � � � Active L�ayer. r fJse Map Tps GiS ���'�� � ;�? �' u� 0 '�' PARCELS {Map Tips Available) . . 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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