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132 Falling Creek Drive Lot 30I Davie County, NC Tax Parcel R ennrt Wednesday, December 21, 2016 Parcel Number: NCPIN Number: Account Number: Listed Owner 1: Mailing Address 1: City: State: Zip Code: Legal Description: Assessed Acreage: Deed Date: Deed Book / Page: Plat Book: Plat Page: Building Value: Land Value: Total Assessed Value: WAKINENIG: THIS IS 14U'I' A SURVEY Parcel Information H9080A0030 Township: Shady Grove 5789624940 Municipality: 82516011 Census Tract: 37059-804 HODGES JERRY L JR Voting Precinct: EAST SHADY GROVE 132 FALLINGCREEK DRIVE Planning Jurisdiction: Davie County ADVANCE Zoning Class: DAVIE COUNTY R -A NC Zoning Overlay: 27006-0000 Voluntary Ag. District: LOT 30 FALLINGCREEK FARM PHASE I Fire Response District: 0.70 Elementary School Zone: 12/2000 Middle School Zone: 003540289 Soil Types: 0007 Flood Zone: 049 Watershed Overlay: Outbuilding & Extra Freatures Value: Total Market Value: No ADVANCE SHADY GROVE WILLIAM ELLIS PcB2 DAVIE COUNTY 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. rermi"ttie'% t t DAVIE COUNTY HEALTH DEPARTMENT Name: + r `{ " z! `" Environmental Health Section PROPERTY INFORMATION t P.O. Box 848 Directtons to property: Mocksville, NC 27028 Subdivision Name:' d�•/!.� ! ' � '� � ;� :, � ,. �: ;�',f �.,,�;..:_ . .�. ,.r ,.. � -751-8760Phone #: 336 � Lot: AUTHORIZATION FOR Section: WASTEWATER " SYSTEM CONSTRUCTION Tax Office PIN::# - - AUTHORIZATION NO: 003035 A Road Name:�- **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building PermitsTh . is -Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Per'mhs: (In compliance with Article 11 of G.S.'Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ENVIRONMENTAL HEALTH SPECIALIST ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE o r # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No • ���� TYPE WATER SUPPLY �� DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE LOT SIZE �� SYSTEM SPECIFICATIONS: TANK SIZE'l GAL. PUMP TAIJK GAL. TRENCH WIDTH '' ROCK DEPTHdA LINEAR FT. As stated in 15A NCAC 18.9.1 (5 OTHER Fccerlted Systems may Also ha 11sg:C REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT �.� yam, r `',� c. C�i 1 U s" (_A .�� �• � � h . 1 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1 OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. OPERATION PERMIT BY: 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 THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHDm102(Revised) 01Cer#1 5„r3` —(/•. / ''tf P.ettiKee"r ; ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directflotito property:r I ` ' r "-� Mocksville, NC 27028 Subdivision Name ' r F Phone #: 336-751-8760 r Section: 1` Lot: ` t - f AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:# - - AUTHORIZATION NO: A Road Name: + 'r zip: '+ 003035 **NOTE** This'Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits" (In compliance with Article I I of G.S. Chapter 130A, Lstella er Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 'r IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE _r" r # BEllROOMS ..�' #BATHS►, # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERC/IAL SPECIFICATION: FACILITY TYPE# PEOPLE # PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE .i t! t a E t TYPE WATER SUPPLY C Lig DESIGN WASTEWATER FLOW (GPD) '' NEW SITE REPAIR SITE , SYSTEM SPECIFICATIONS: TANK SIZE L r_ GAL. PUMP TAN GAL. TRENCH WIDTH �" ROCK DEPTH A�L/1— LINEAR FT. OTHER rs i REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT j, L , `, t } A7 c.�` �. • Lt CIA FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT - SYSTEM INSTALLED BY: AUTHORIZATION NO. OPERATION PERMIT BY: 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 THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 07/02 (Revised) !%rGr]' 5-� �•- 73 5t? - T ss Au RIZAATION NO: 2 010 DAVIE COUNTY HEALTH DEPARTMENT ERTY INFORMATION Perrruttee's ,.• �,�� .A�+eQ. Environ P.OtBox 848 _Section PR P Name: a Mocksvtlle; NC 27028 Subdivision Phone #.336.-751-8760 Directions to property: ,'�,'�iv,; /,�`�"�'� /`*� Section: Lot: d AUTHORIZATION FOR �6> WASTEWATER.`J SYSTEM CONSTRUCTION Tax Office PIN:# Road Name. *NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building -Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater. Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. . ' - ENVIRONMENTAL HEALTH SPECIALIST, DATE ISSUED DCHD 05196 (Revised) 'F 1'�`My'�(V'�'1I�'ys _. T ^v. I. .rl w �.. ♦ _. - a 1wi+._..- ' t -..:may �,M1 1 n - a - ,_ . _ r • . w r. J� Ufa• ' DAVIE OUNTX HEALTH DEPARTMENT V PROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Name.;'" ».--A--�' "r---.""=—•–. =" Subdivision Name:. ,. ' Directions to property: Section: Lot: IMPROVEMENT�8�2'— _ - PERMIT' . Tax Office PIN:# - - - Road Name: Zip: **NOTE** This Improvement Permit DOES NOT authorize the construction or installation 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) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE F PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE 11`11S PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING,TYPE �_ # BEDROOMS_ # BATHS _,�2- # OCCUPANTS GARBAGE DISPOSAL: Yes or No Mme. COMMERCIAL SPECIFICATION: FACILITY PE # PEOPLE # PEOPLE/SHIFT # SEATS INDDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPL { t, ' DESIGN WASTEWATER FLOW (GPD) NEW SITE I✓ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH --` - ROCK DEPTH LINEAR FT.7?C1 d / OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: I ( % � �J IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLUERT FILTER* *RISER(S) IF G" BELOW FIRIS11ED GRADE`* - rr **CONTACT A REPRESENTATIVE OF THE DAVI.'COUNTY F BETWEEN 8:30 - 9:30 A.M. OR 1:00 -r30 P.d.. ON THE OPERATION PERMIT SYST j� 1 r' 'o r DEPARTMENT FOR INSTA IIATION. TE !;1 'ECTION OF THIS SYSTEM # IS (336)751-8760. AUTHORIZATION NO. Eg4j OPERATION PERMIT BY: DATE: //-14M r. Z/_ t � . **THE ISSUANCE OF THIS OPERATION PERMITtN.1900 IN&CATS THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 1307; SE "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NOWAY BETAKEN ASA GUARANTEE THAT THE SYSTEM WILLFU I ISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96 (Revised) %�'"D I APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT Davie County Health Department Environmental Health Section P. O. Box 848 Mocksville, NC 27028 (704) 634-8760 ------- 7-77�-: ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSEI UNL M ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Pl"me to be Billed k1la5v- beil" � Zy'. Contact Person 61"4v Property Dimensions: qq,rp 74 Mailing Address .22 2,5— -5,JVA r t, C'> n A, 016/ )C4 Home Phone Mocksville) TO PROPERTY.,, f City/State/Zip 4 NCO 71P 3 Business Phone lqc- ?44 toy 6 1: s: ?evdem 99 k -'2 /-a .0 2. Name on Permit/ATC if Different than Above Sod me -- -ction:jo Mailing Address City/State/Zip 3. Application For: 0 ---Site Evaluation C3 Improvement Permit & ATC El Both 4. System to Serve: 0 House 0 Mobile Home 0 Business 0 Industry El Other 5. If Residence: # People # Bedrooms # Bathrooms L: Dishwasher 0 Garbage Disposal C3 Washing Machine El Basement/Plumbing El Basement/No Plumbing 6. If Business/Other: Specify type # People # Si. # Commodes # Showers # Urinals # Water Coolers If '-"oodservice: # Seats Estimated Water Usage (gallons per day) 7. 1 ape of water supply:Q County/City 0 Well El Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? El Yes Q No If yes, what type? PROPERTY INFORMATION REQUIRED: ***IMPORTANT*** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: qq,rp 74 WRITE DIRECTIONS (from. Tax Office PIN: # 5.2 9j 63 s7o3 Mocksville) TO PROPERTY.,, Property Address: Road Name 4 City/Zip Abp wle4:9 lqc- ?44 toy 6 1: s: ?evdem If in. Subdivision provide inform tion, as follows: AM7774�' ,b Y6�r CA) I ame: -ction:jo Lot #: This is to certify that the information provided is correct to the be i s't of my knowledge. I understand that any permit(s) issued hereafter. are su1ject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsif: J or changed. 1, also, understand that I am responsible for all charges incurred from this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County to conduct all testing, cedures and owned by as necessary to determine the site suitability. DATESIGNATURE�&Zz- 2 Revised DCHD (06-96) C yt kc, j r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION---/ Soil/Site Evaluation APPLICANT'S NAMEDATE EVALUATED PROPOSED FACILITY AA PROPERTY SIZE SUBDIVISION /7 (_ rGL' �- ROAD NAME Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public jI FACTORS 1 2 3 4 5 6 7 Landscape position ' Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH }' Y 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: es LONG-TERM ACCEPTANCE RATE: I r REMARKS: DCHD (O1-90) LEGEND Landscaue Position EVALUATION BY: OTHER(S) PRESENT: 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 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 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 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC av,� Sb Davie County Health Department `� Env/tronmenfal Health Section [� W� P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 .. 49O ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS to-�= �-� INFORMATION IS PROVIDED. Refer to the INFORMATION BULLE21H 1. dame to be Billed 61--A-lZt OLKC Contact person ac -Dor -1 `L1i tI7—)E4 Hailing Address 6- (2 time Phone _ Up-(ocij% city/state/Zip t"Ct) i/�-,t1 C� /vC 2-20 Business Phone _'q4n-6q4 7 Z. Name on Permit/ATC if Different than Above Nailing Address City/state/Zip 3. Application For: U Site Evaluation q(Improvement Permit/ATC ❑ Both 4. system to service: X House 0 Mobile Home 0 Business 0 Industry 0 Other S. If Residence: # People # Bedrooms 3 # Bathrooms Dishwasher 0 Garbage Disposal Awashing Hachine 0 Basement/Plumbing 0 Basement/No Plumbing 6. If Business/Industry/Other: Specify type # people # sinks # Commodes # showers # Urinals # Nater Coolers IF FOODSERVICE: # Seats Estimated stater Usage (gallons per day) 7. Type of water supply: County/City 0 Well 0 Coamanity e . Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes NINo If yes, what type? *"IMPORTANT"" CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED' BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: iZ& * Z4v � 12 #- Flo Tax Office PIN: Property Address: # 5-91 T 6 3.57a 3 WRITE DIRECTIONS (from Moclsvilie) to PROPERTY: Road Name e -e hK City/Zip a / a d If in a Subdivision provide Information, as follows: Name: i rk(,L i IU Fr 6e6ey Section: I_ Block: Lot: I> 0_ Date Property Flagged: —41,DA 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 roponsiblefor all charges Incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County ealtb 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 sultollity. DATE 2 S SIGNATURE THIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Exisig and proposed property lines and dimensions, structures, setbacks, and septic locations). LA Account No. 3� Revised DCHD (07/98)-- -- Invoice No. 6,Qo 2 2 -CJ U 2O ..J.b.wr I-- ti. P -m 7 'i..r �•� 24 .'wP. ..i i..r.. i.•.d � ti •u....JhrwrV 4..r •..y�...y >w !`...� "V... I N t1' 1.290 Ac.i D.8.162.P9.600 9 .... r .,war ti "..M ►.e \ v • ate- N a e � r ODM - bir..w \ ate' .raw Y.� EYP � Y..Y..�iF M YIrYw • 9iI Y.r r�l `w. �IY.M Y.w.. rY�1 �.t. I -- w W Ito IW Or r F 6.Pq IPlk1B4 ---� I ( � 430 ,48.79' CO ��� • N.r. w - u ru .� . �r 1 \ r ,�� V A. • 1 M 0.71©t 248.78• ;74 N05.28'36'E 7 Q 24 a � ti u N t1' 1.290 Ac.i D.8.162.P9.600 \ \ -5- 2.496 Ac.i C-24 1 0.831 Ac.t ` 1S © or J 241.06' u I 4? 0.71©t 248.78• ;74 N05.28'36'E wr r 0 J n • 1% 21 -' a =� X237 6•kt'•w ~ 0.704 Ac.! • �r. w � ti is W 140.43' 97.18' ij N00 pt'09'E v 122.47 108.16' /17.15 126.00' 128.00 99 1126.70' I o .01 239.00' J \ I I110.00' 129.00' ; - 1 - , N 00 �. r 0.694, �CA �+ E OAPO Ac.3 ,,, 0.69 3 N a u 0807 •c 0.692 Ac.t ; . +A. SL a 0.705 Ac.t Id g (, 0.700 Ac.: o N 0.69 Ac.! S S �r �• O1 !`r 0.701 Ac.3 �' ] _ c\ 0.689 Ac.t N ri`' y� �' S �.J g"� �' �!In „� Lp 33 �I f11 [3a R 14 a 19 1 O I O I 0 30 0 32 p 1\ y - q 20 r I� �sr.rG c�•t h \� � I . OS D 70 SIGHT a X16 30.x. ,- I Q A A1EHT. ICA125.00' 126.00 - 108 SZ' C-29 C_k \ n,B c_3. -1 DB `� 129 W' _ v _ 16.26' - - - - C -3r` --N1s C-17 C-18 51.59' - 1!T / 3e 33• - CO v FALLINGCREEK DRIVE No1�,o5:o'•E c_32 \ 90 Q C_13 134.84. E C-33 H00'36.43'w - 60' PUBLIC i�7WT .1 h�� zzo.z7 O - - 126.00 N 100.00, -1 OZKO. > - 125.42' 123.00 n 6.30. r c_14 eZ, / .q 7. '.� C-13 C-12 � � :U � ; 0.704 Ae.t !� • O O s 5 g z m `ti o TkAc. Hs7,3.••M 703 Ac.: "•"n Aza7a o �.1r0.t n �cil0 870 Ac i n O 235.09' V a n g - '�^ 0.692 Ae.t ? ece+ e• •. wr r r w sr r..r r Parcel 41, To. Atop H-9 / \ J. Harold E. Cres D.8.162.P9.600 \ \ -5- \ / or -4- \ © Parcel 40.01, i'nteCr \\` .s J` O 1.028 Ae.3 80.8.6,P9.777 wwS o G�\ 01 \ iriV^J C1 T 1 si E Si ;e 9t6 g 0.774 Ae.* 1a 237.08' SOS 28'36'W = c�•...ppp�\ / Parcel 40. Tam map H-9 \ John A1ey D.9.76.P9.371 \ D'7 \- .�2' 11 pIr 0gsd`\ \\ 1(nP1{ \ 501�7'3S•W / . rte/ S05'42'44'W, i --368.27'230.63' 15160' S01'19'05•w 124.90' W 140.43' 97.18' ij N00 pt'09'E v 122.47 108.16' /17.15 126.00' 128.00 99 1126.70' I o .01 239.00' J \ I I110.00' 129.00' ; - 1 - , N 00 �. r 0.694, �CA �+ E OAPO Ac.3 ,,, 0.69 3 N a u 0807 •c 0.692 Ac.t ; . +A. SL a 0.705 Ac.t Id g (, 0.700 Ac.: o N 0.69 Ac.! S S �r �• O1 !`r 0.701 Ac.3 �' ] _ c\ 0.689 Ac.t N ri`' y� �' S �.J g"� �' �!In „� Lp 33 �I f11 [3a R 14 a 19 1 O I O I 0 30 0 32 p 1\ y - q 20 r I� �sr.rG c�•t h \� � I . OS D 70 SIGHT a X16 30.x. ,- I Q A A1EHT. ICA125.00' 126.00 - 108 SZ' C-29 C_k \ n,B c_3. -1 DB `� 129 W' _ v _ 16.26' - - - - C -3r` --N1s C-17 C-18 51.59' - 1!T / 3e 33• - CO v FALLINGCREEK DRIVE No1�,o5:o'•E c_32 \ 90 Q C_13 134.84. E C-33 H00'36.43'w - 60' PUBLIC i�7WT .1 h�� zzo.z7 O - - 126.00 N 100.00, -1 OZKO. > - 125.42' 123.00 n 6.30. r c_14 eZ, / .q 7. '.� C-13 C-12 � � :U � ; 0.704 Ae.t !� • O O s 5 g z m `ti o TkAc. Hs7,3.••M 703 Ac.: "•"n Aza7a o �.1r0.t n �cil0 870 Ac i n O 235.09' V a n g - '�^ 0.692 Ae.t ? ece+ e• •. • A`' '``15 • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT &ATC L5 @ 15 ow Davie County Health Department Environmental Health Se+ fw JUN 2 2 2000 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 LK ***XNP0RTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed`,/l%4/rde. S C� Contact Person :5i4 ^ e � Mailing Address /f %i ,P;t a X!'12n 5=4-5=4-•7 Home Phone y� "7 / 7;;;r city/state/zIP ! {,tl=SCf= G�-e ate, �/62-3 Business Phone 3� 2 2. Name on Permit/ATC if Different than Above Mailing Address City tate/Zip 3. Application For: —B -Site Evaluation E, Improvement Permit/ATC ❑ Both 4. system to service: ---B House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People # Bedrooms_ # Bathrooms 3 �-B Dishwasher -- Garbage Disposal --H Washing Machine --off Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # C # showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of Water supply: -x-41 County/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ---0 No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESUBMITTED by the client with THIS APPLICATION. Property Dimensions: /X ' q A� Tax Office PIN: # �'�/ �' �Z_%4�d Property Address: Road Name /.4I11 -21C city/zip Ah-hiw' IV6 2,7oo6 If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: 1 -r 47 Ta yo(/C- r Date Property Flagged: 4K , no 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.) ,f DATE^�'v2'� �O SIGNA ' 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. D.