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235 Falling Creek Drive Lot 37Davie County, NC Tax Parcel Report 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: WAKNM i: 'l'Mb ILS 1VU'I' A SURVEY Parcel Information All data is provided as Is without warranty or guarantee of any idnd either expressed or Implied including but not limited to the implied warranties of merchantability or fitness for a particular use. All users of Davie Countys GIS webalte shall hold harmlessthe County of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or Inability to use the GIS data provided by this webaRe. H9080A0037 Township: Shady Grove 5789740121 Municipality: 82521884 Census Tract: 37059-804 TIMIDAISKI JOSEPH H Voting Precinct: EAST SHADY GROVE 235 FALLINGCREEK DR. Planning Jurisdiction: Davie County ADVANCE Zoning Class: DAVIE COUNTY R -A NC Zoning Overlay: 27006-7659 Voluntary Ag. District: No LOT 37 FALLINGCREEK FARM PHASE II Fire Response District: ADVANCE 4.82 Elementary School Zone: SHADY GROVE 12/2003 Middle School Zone: WILLIAM ELLIS 005260982 Soil Types: PaD,PcB2,PcC2,ChA 0007 Flood Zone: 0189 Watershed Overlay: DAVIE COUNTY Outbuilding & Extra Freatures Value: Total Market Value: 161 Davie County, NC All data is provided as Is without warranty or guarantee of any idnd either expressed or Implied including but not limited to the implied warranties of merchantability or fitness for a particular use. All users of Davie Countys GIS webalte shall hold harmlessthe County of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or Inability to use the GIS data provided by this webaRe. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital street Mocksville, NC 27028 (336)751-8760 Account #: 990002984 Billed To: Joe Timidaiski Reference Name: C/ir',s jjo kY,sa^ t -acuity: Kesioence ATC Number: 3629 Tax PIN/EH #: 5789-74-0121 Subdivision Info: Falling Creek combin.42&43 Lot # 37 Location/Address: 235 Falling Creek Drive -27006 t-roperty size: 4.t acres 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 WASTEWATER CONS AL FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur . Date: 1117& /,C)5 CERTIFICATE OF CON , 30 **NOTE** The issuance.of this Certificate of p e ton s fie descr d o prov Operation Permit has been installed in compliance with Article 11 of G.S. Chapter ion . 900 ` wage Tr titent and Disposal Systems," but shall in NO WAY be taken as a g tee that the s will fun n satis rily for any given period of time. tO P&-11 q0 �q &0 r Septic System Installed By: L �� Environmental Health Specialist's Signature: DCHD 05/99 (Revised) C Account #: 990002984 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Billed To: Joe Timidaiski Reference Name: (f / -%r e 5 3.7. ANso� Proposed Facility: Residence Tax PIN/EH M 5789-74-0121 -Z,00 Subdivision Info: Falling Creek combin.42&43 Lot # 37 Location/Address: 235 Falling Creek Drive -27006 Property Size: 4.7 acres ATC Number: 3629 **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 I 1 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 HONC #People 3 #Bedrooms 3 #Baths 7 - Dishwasher: 9!( Garbage Disposal: ❑ Washing Machine: Id Basement w/Plumbing: ❑ Basement/No Plumbing: Gd 111 Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 4.1 et�%c, Type Water Supply OVLWry Design Wastewater Flow (GPD) 3100 Site: New 12� Repair ❑ System Specifications: Tank Size 0IOGAL. Pump Tank GAL. Trench Width Rock Depth IZ-" Linear Ft. Other: -n Required Site Modifications/Conditions:. In1STA�-1`- G�ibt12, �3�' �� OFF— o' D*�'P IMPROVEMENT/OPERATION PERMIT LAY UT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact areative 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 . .in. the day of installation. Telephone # is (336)751-8760.**** SEA a �� Environmental Health Sp ialist's Signature: DCHD 05/99 (Revised) t til NyY ' OI-LNL.. Sc�11— Jul 29 04 03:12p ` p.2 APFUCATIO'd FOR SITE EYALUATWN/fItPROWMENf PERM k ATG Davis County Heahh Department Environ//renta/HmUhSecilon � I.O. Box 848/210 Hospital Stroot Mocksville, NC 27028 (336)751-8760 •••InFORTANT." THI5 APDLZCATION CANT OT BS PROCBSSRD MMISS ALL THU RLQUrRS0 IHYDMTIOH IS VROVIDIID. Refer to the, *IPF MOLTION BDLLETIW Lor SnVLXUatiotid. 1. Irene to be Billed G 3 ByILO/ M 6 £ E-Ve , LLLCConteet Pesaoa G up -i S �.; 2 HAISc) Meiling addreaa Z33 { cc/AJVC1t�jK, UE , none rbo.e .,3, C!' --9,4V—?-78 city/st.t.rzn evil-lCE, AM Z700 (v Buune., Pb000 33(v- 414 ` 49o8 a. none v V—dt./nrc it Dllforaat then elbow mailing addreao City/state/tip 3. Appllcatioa rort __zlbrit:a LValuation (3 Improvement Aatmit/ATC C.1 Both a. system to service: FYtt,,ouea ❑ Mobile neer% 0 nuaineao ❑ Induotry 130 tiler 5. Type epoten rov.stL7ed, ;r=n—tivwl tl conventional. >,odttied❑ innovativo i a. 2f Beeidenee. a People • Bedrooas _ a Hathro®ea Z� 211iahe.ahar ❑aarbage Dtsporalsehing faehlne ❑Bearmeat/Pluoaing GBssanen'/Iro elvbiae 7. If Besiaeee/llyduelxy /other- verity type a people • Dinlu a emaodea a 8 -Overs a Veinale • Water coolare IF FOODSTMCLc1 # Seats Estimated Water Diage (yenoee per dayl i e. Type oc ..ter ouppnr, F reounw/City ❑ Well ❑ COnmunity P. Do you anticipate e"Ltiona et etpaoSiotu bribe facility this system is intended to serve u Yes I 13 -No If ytx, what type? j•••lAlPORTAN7'"'"'t ULWS MUS7 COMPLEMTHE MQUIREDFROtfiRTYINFO1iAIATIONI(EQUESTED BELOW. iiffieraPLAT orSft9FLAN MLSTBLSUBMlTMDbyCh. cReet WMtTRIS APPLICATION. I ProptrtyDitnensiom: 3157E /4TTAc-HEU L±41 CO WRMV?RWnONS(k*aiModO TasO(GeeriN: N i�9%4 DIZ( L.S�2 E �� Dei N -J, 4o'T 'fF 3`l.Y Property Address: RoadPtamay-4ttrnk,<r2ti'�DFe; ��r�/�CES � CUK CityrllpAJ G ��'T rn --Jtis, 7�e En if in a Subdivision provide irtformalion, as toilows: Z3 3s 2 3 Z r»e: FAZ&W& 6F_F1c Section: Block: _ — Lot: Date bonne ierners Ragged: J fi! 9 ol5o lip o3-7 This i7 to certify that the information provided is correct to the beet or+r y knowledge. I understand Issued bercafler arc subject to swpea don or revocation, if the site pleas or intecded use change, or i subndtted fa teas applkgda0 Is f"t:f d ar rbanged. 1, also, mrdastaud thatl air responsible Jar all r this applicafivA I, hereby, give content to the Authorized Representative of the Davie Comity Heap to enter opoo above described property located in Davie County and a+vned bj moi` f / t+t /G to conduct all testing procedures as necessary to determine the site suitability. . DATE /%z-- �a i SIGNATURE / THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: M property lines and dimarutans, structores, setbacks, and septic toeatious). ' Sign givrn Revtstd DOW (05/03 .h Account Ne. Invoice No. iMOPERTY: O Sc;vTN/ LF -F -T cw/?//E Z"( L. Err- rwro any perodt(s) inforaution rs laatrrad Jroor sartment �� -i- k'�/:GEEN i An/JdEIZ L and Proposed it Charge dc: ,Jul, 2,9 04 03: r2p Davie County, North Carolina Spatial Data Explorer z O �svieIE slia :we 0U N.( hlutlYl l31'QIIli3 Click on the Map to: 2aomini ZoomOut ; 1 Recenter Map ice' Identity PaCC21S y Zoom Factor: 2X Radius Search (feet) U f 29 75 73 i1V 2.31 A 7245 e 2.44A iW 5129 �$ 't1 rJ f'�ti 1Ag r 7i LaT 37 4•7M740121i 0121 yg 37S 114 r3� ICA +¢ _.49 11078 �.NA, Parcel Data Find Adjoining Parcels 7! p.3 Page 1 of 2 Map Li Draw L Draw seleci [] Census Tri City Bound rj County Zot Multi Syi ❑ E911 Fire 0 Ej Flood Pane ri Flood Zone O Parcels School Diss Multi Syi [� soils ❑ Town Zonli C Townships Multi Syi D Votina Prot Infrastructu El, Driveways ['l Rail Lines V Street Cont USINC Higl Multi Syl Aerial Phot Crooks and ❑ E911 Addr( Fire Depart Schools Draw L MAPCl This map is prep: inventory of real t within this jurisdi( compiled from to plats, and other j: and data. Users ( hereby notified th aforementioned f information aourc consulted for veri information conla map. The Davie I 7/29/2004 • Land Unit /Type: H f080A0037 J AC i Deed BooWage: 00525 ! 0982 • Deed Date: 2003112110 • County JD., H9080AD037 Safes Price: $41,000.00 • Account Number.82521884 • Property Address: • PIN: 5789740121 • Legal 110T 37 FALLINGCREEK FARM • County Zoning: R -A4 • Owner Mame: TIMIDAISKI JOSEPH H • Census Code: • Owner/Address 1: TIMIDAISKI JOSEPH H • City Code: • OwnerlAddress 2. TANNER KATHLEEN M is Fire Disinct: i • Owner/Address 3:1058 MANRING ROAD . Flood Zone: ZONE X • City, State Zip: LEWISVILLE .NC 27022 - 0000 • Flood Community- 3 70308 • Land Value: $42,970.00 • 1 Flood Panel: 0100 C • Building Value: $0.00 • Flood Map Date: 12;17-1993 I i http:/166.208.132.254/servlettcom. esri.esrimap.Esrimap?Name=Davie&Cmd=Clk&Left=1... p.3 Page 1 of 2 Map Li Draw L Draw seleci [] Census Tri City Bound rj County Zot Multi Syi ❑ E911 Fire 0 Ej Flood Pane ri Flood Zone O Parcels School Diss Multi Syi [� soils ❑ Town Zonli C Townships Multi Syi D Votina Prot Infrastructu El, Driveways ['l Rail Lines V Street Cont USINC Higl Multi Syl Aerial Phot Crooks and ❑ E911 Addr( Fire Depart Schools Draw L MAPCl This map is prep: inventory of real t within this jurisdi( compiled from to plats, and other j: and data. Users ( hereby notified th aforementioned f information aourc consulted for veri information conla map. The Davie I 7/29/2004 o.. N 1 APPLICATION FOR SITE EVALUATION/IMPROVEMFM PERMIT & ATC Davie County Health Department ` j J� 0 3 Envfronmenf it/ Heath Section l P.O. Box 848/210 Hospital Street Mockoville, NC 27028 (336) 751-8760 - * * * neQRTANT* * * THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Hams to be Billed i ( I I I�Yin� d a ii L i Contact parson T 1 h d ire LA) lJ i U bo YDS Mailing Address 10!SB Man 1 O i Y1 some phone (�3(I�_ - S((�((��A - g 3 9 q City/state/zIP I e a riot z Business phone ii3CQ _gLgq —DQ ,_ Z 2. !tame on Perait/ATC if Different than Above !sailing Address 3. Application For: 9"Site Evaluation e. Systam to service: "CUBS ❑ Mobile Home S. • If Residence: # People City/state/zip ❑ Improvement Permit/ATC ❑ Both ❑ Business 0 Industry 0 Other # Bedrooms 3_ # Bathrooms a eDishwasher 0 Garbage Disposal Washing Machine 0 Basament/Plumbing 0Bssemant/xo Pinmbing 6. If Business/Industry/Other: specify type # People # sinks # Commodes # showers # 'Urinals # dater Coolers IF FOODSERVICE: # Seats Estimated Nater Usage (gallons per day) 7. Type of water supply: 9,-6ounty/City 0 Well ❑ Community a. . Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes 0 No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTRE SIMM77ED by the client with THIS APPLICATION. Property Dimensions: . lyr— Tax Office PIN: # 57W —;W iB 1,121 Property Address: Road Name, -.V35- Fa Rd" e',w-e DY City/Zip civ a ive e, Me. O&Z If in a Subdivision provide Information, as follows:. Name: iL[ ti�i Section: Block: Lot: 7 WRITE DIRECTIONS (from Mocksville) to PROPERTY: 12r 4 e 5 � Ai cJ 1- ITI 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 nae change, or if the information submitted in this application Is falsified or changed 1, 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 HealthDe,P�rtment to cuter upon above described property located in Davie County and owned by l.I 3il Dtk,e O4iXe to conduct all testing procedures as necessary to determine the site suitab DATE / / '� SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property fines and dimensions, structures, setbacks, and septic locations). ^?' NOV-05-103 WED 12:05 ID:VIRTUAL INK LTD TEL NO:336-593-9404 N x1072 P01 uni rLnn i JOSEPH TIMIDAISKI &KATHLEEN TANNER LOT #37 FALLING CREEK FARM APPUCATION FOR SITE EVAUTAT10N/IMPROVEMENT PERMIT & ATC Davie County Health Department Envdronmenta/ Mealth Secbfon P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 D RRC 0 W R JUL 2 4 1999 ENVIRONMENTAL HEALTH MUM I'M I ITV ***XMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED IN1rOR1,9LTION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. llama to be Billed WESC N,3 hr-vEL<j0)'"ENi' Mailing Address 2011 Pw jjJat_()d \ZcAL` City/state/s:2 Ww5 1 0,.- 2. Name on permit/ATC it Different than Above Mailing Address Contact person 3ca►n' (57,:nFmcy Basis phone S36 ibc7 •?038 Business phone 336 •77-7 - y!1 7,q City/state/Zip 3. Application For: e8ite Evaluation ❑ Improvement Permit/ATC ❑ Both e. system to service: i7 House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms ?J-� # Bathrooms dDishwasher d Garbage Disposal U washing Machina ❑ Basement/Plumbing ❑ Basement/No plumbing S. if Business/industry/other: Specify type # commodes # People # sinks # showers # Urinals # water Coolers IS FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes C!'No If yes, what type? ***1MPOR7ANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN ME ST RESUB-HIFI icD by the client with THIS APPLICATION. ,1 Wit. - Property Dimensions: 2--,(ALuA"i4^<-EK (OAcelco) WRITE DIRECTIONS (from Mocksville) to PROPERTY: NO kf A3 s.]_ Tax Office PIN: # 5785-6 1 0RL 1JWJ 6-1 MST , LEfT caJ �6(I ft 141F Property Address: Road Name `/bUaklRC fc 0R -W <'"' R--Ip`f� r'tc-c-K City/Zip A0vAH1c-,K1- 27cr(; If in a Subdivision provide information, as toll Name: FA �L#c R(f-K Tq t, 0 6 ptyivxn L) / Section: Block: U R Lot:+_ Date Property Flagged: 181 ctrl 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 1 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 7 119 29 SIGNATURE r I THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the f owing: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). NE W SAP 1,6Y 37 Revised DCHD (07/99) Site Revisit Charge 1 Date(s): I Client Notification Date: EHS: Account No. 124�; Invoice No. i \ Shartlrock Acres I �. TAMA M. O'MARA PB 6 Pg 183 & 184 \ DS 157, PG 69Z, \ ` 14 I 1311 , ' \ 1 `\ \ 2238.60' I \ \ 81 ` 1 f \ \ N 72`0 \ \ \ 730 7 4- . _• \ V"'tel / _ 626 • / '1, 0 \ � "— _ 1Q9h� u • \ t / N i 40 S ' 2 I 2 92 23.5 • N 92 t?¢mDvad Con5t. 210 hale ]t 150'0 47 i M \ 237.61' 140.43' 97.18' m / j l II 7 \ \ LL u \ e 110.0u� PT R = 150' 1g EHi9t1119 g�'Ici�;RF,S \ v �1 0 1 be re eyed op� \ \ Side Dite1) `\ Matting (Tjr •% \ .04' Con5t• CTYR) by 97' , ^ N05 3 ZO"E 0'36• ►e 84.08. g 43.70' 90.37 LLJ to '0 4 I Tem po/ ory ©1 = 0 0.76- 0) Sedinlell} 1 R 3.61 c �• Jj -I I '• STONi 'OUTI£T STRUCTURE 9-64' 104.8a---- �,\ J \ TfOP / S(�,'•r• 1 /�� 10'I�ii1a,w.1 3 2 C}:468'A" 5 DNE R = 500' F� 16 15 1 APPR46KIMATE N 25 LIMITS op 14 r-71 STUF?560 \�REA N w \ Lq Ln \ \ \ :� �. \� 766' `` � •. N 1 46j. \1 \� s �� '• >>2• EXISTING LAKE Parcel 42.05 I I \ �/ b Vanda Goye Hoots DB 138, Pg 288 -160 �I �0 G DAME COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 989900136 Billed To: Westview Development Co. Reference Name: Brant Godfrey Proposed Facility: Residence Property Size: Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5789-64-7482.42 Subdivision Info: Falling Creek Sec.TlBlk 42 Lot # 42 Location/Address: Falling Creek Drive -27006 See Map Date Evaluated: a -"fz Community Evaluation By: Auger Boring Pit Public o1� Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % HORIZON I DEPTH %D Texture group Consistence Structure r ' & 7 , Mineralogy HORIZON lI DEPTH 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: LONG-TERM ACCEPTANCE RATE: L REMARKS: EVALUATION BY: // OTHER(S) PRESENT: 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 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 DCHD 05/99 (Revised) APPUCATION FOR SFE EVAUfATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section . P.O. Box 848/210 Hospital Street Mockoville, NC 27028 (336) 751-8760 JUL 2 0 1999 ENYIRONNIIENTAL HEALTH ***I11P0RTA1M'*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the IN11'ORMATION BULLETIN for instructions. 1. Name to be Billed W�STV��vJ DiV�I.oYT^F1J;' CLWO A.P1 Mailing Address 2 b sl RC tNaL ga 1Zcq� Contact Person 3Ri:�11 67,ZnFNC-y some Phone city/state/SIP WWI 1 Lk- 2'RvL Business Phone 33b '77-7 -0,.17,- 2. 0,.17, 2. Name on Permit/ATC it Different than Above Mailing Address 3. Application For: Site Evaluation 4. system to service: House ❑ Mobile Home 5. If Residence: i People _ E(Dishwasher E(Garbage Disposal City/stag/Lip 0 Improvement Permit/ATC ❑ Both ❑ Business ❑ Industry ❑ Other i i Bedrooms -J-'F # Bathrooms O(washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/other: specify type # People # sinks # Commodes # Showers f Urinals # water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of rater supply: Ci County/City ❑ Well 0 community a. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes d"No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION R1rQUESTED BELOW. Ei.uer a PLAT or SITE PLAN MUST SESUB-MI TED by the client with THIS APPLICATION. ,�1•SsE Property Dimensions: -)�O- 4 2-, (AWAA�4^«K (0*0(0) WRTTE DIRECTIONS (from MockrAlle) to PROPERTY: P: �o tri' 33 i'J,,uJ p, CC -K i ; L Tax Office PIN: # S761�1-44-a4fcL ffi4v 6-1 ( Si', Lc -FT. c"/ 96(1 fLic;uT' Property Address: Road Name `AUAW,, 4� Dn:\*: rw i (,PLEA Cm -<-K City/Zip ,AID vA,,,tc.,:jc '2T -c%4 If in a Subdivision provide information, as foil Name: FATq � a �S c,L 'c'ft EE�I VPNJV;,0 L) �J Section: Block: R U Lot: Date Property Flagged: 8 cj ci 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 1 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 "7 1/9 12 i SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the 011owing: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): I Client Notification Date: I EAS: Revised DCHD (07/99) Account Na 14; Invoice Na III I Shamrock Acres ' \ TAMA M. O'MAkA I � y � ` PB 6 pg 183 & 184 I \ DB 157, PIS 697, 14 \ \ 13 — — 2238.6 415.1 �77 \ 81 10 . . ......... Vy J A I o \ 720 \ \ 7.30 474 TQ 101 92 —710 40 s \ 92' 223.59 `\ 2j4' Hxi3t, Bid Tc 13e / RegI Co St. 270 hast- I Z: 47 750• I g 237.61' 6 \ \ \ 140.43' 97.18' m • I 4 � �j � Y 4 110.07 1 \ \ \ 18 IJ 37 \ \♦ PTS R = 150' 19 ci Sale DItc4� N 1 , 6e rembv II �! \ _ �h \ \ Mat -king (Tr •i Const, CTYR) \ 6;�4053 m O"E �h z 1 \ \ JO 64.06• /•�,' N8 43.70' W h I % _ 9�.3 CD O 4J ,I Tcrapc�°ty ©1 r.�� �R = �` 0 1 _1�� _ Sedim?.nt 6 Jer_964 %6+. ' �'fQ / f 6lai i uTIET STRUCTURE 9-64 104.88' 3 2'i /a ��' � is 69 -A -s1 ams �R = 500' 16 15 \ \ �25'� � • ��� oil \ n15TUROMO 14 7 it \ 0.\ �' u Cp=c3`; \ \ I \ \ \ \•• � ar' 1� � 4g7. J� Iry ' v EXISTING LAKE Parcel 42.05 I I Wanda Goye Hoots / DB 138, Pg 288 I I %ice I 1 Q01