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450 Country Lane Lot 2DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002723 Tax PIN/EH #: 5739-51-0949 Billed To: Jennifer Harbin Subdivision Info: Country Lane Estates Lot # 2 Reference Name: Location/Address: Country Lane -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3448 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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). 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 // #People #Bedrooms --? #Baths Dishwasher: 000' Garbage Disposal: ❑ Washing Machine: ;e Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: New PJB Repair ❑ System Specifications: Tank Sizg% GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width Ylc f Rock Depth /,I ` ' Linear Ft240 r IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative 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. too U3'6.m. on the day of installation. Telephone # is (336)751-8760.**** r Environmental Health Specialist's Signature: Ad Date: DCHD 05/99 (Revised) DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002723 Tax PIN/EH #: 5739-51-0949 Billed To: Jennifer Harbin Subdivision Info: Country Lane Estates Lot # 2 Reference Name: Location/Address: Country Lane -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3448 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 CONSSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: '41412 Date: S]�% CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit 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. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) u Date: /J` I&, -6s 1/ • • .PPtlGATt0N FOR SITE EVALUATION/IMPROVEMENT PERMIT & AT O avie County Health Department • • ,.jk AI�J. In`W - H11�f3H 1tl1N3WN�9TIS1T�1 Enviromnel7ta/Hea/th Section P O Box 848/210 Hospital StreetOn� T / r L603 Tfl Mocksville, NC 27028 F0 0l V APR 3+ 0 2003 j (336)751-8760 � * *ION CANNOT BE PROCESSED UNLESS ALL T ED I er to the INFORMATION BULLETIN for Inst 1. Name to be BilledContact Person�h�� Mailing AddressV3,��4'�` Home Phone City/State/ZIP N v �Y�V��C /yW Business Phone �ry�W�V1 2. Name on Permit/ATC. if Different than Above Mailing Address City/State/Zip 3. Application For: Site Evaluation Improvement Permit/ATC Both 4. System to Service: House Mobile Home Business Industry Other 5. If Residence: # People �_ # Bedrooms # Bathrooms Z Dishwasher Garbage Disposal ashing Machin Basement/Plumbing Basement/No Plumbing 6. If Business/Industry/Other: Specify type ��v-i # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County ity Well Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? Yes No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: Vim;� -y' �0�� WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # Property Address: Road Name T !- 70 r s City/zip V�!\�LV�Sy�� VAC `� ��-yv�``� �� q-, 2 Z'� If 22�div' 'rovide information, as follows:Z o� _ Name: �+ra� ��• 5 pC t�0 �Si.�. �'"�� L��F> Section: Block: Lot: Date home corners flagged:�J-\�03 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 u, ee change, or if the information submitted in this application is falsified or changed. I, also, understand that I an: 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 O'S SIGNATURE x THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (In ude all of the following: Existing and proposed property lines and dimensions, structures, setbacks, nd septic locations). r EHS: Sign given Revised DCHD (07/99) Account No. -3- Invoice Invoice No. -S 3 avie t_ounty, i ortn arojina pada ata r.xp orer Page 1 of 2 DwM- STI3iial Daia F3WF Dro- Nixti Carolina Click on the Map to: Zoomin r ZoomOut C' Reoenter Map f Identify: Parcels Zoom Factor: 5X r Radius Search (feet) lv — N W "A • Parcel ID: H4140B0008 • Account Number.OW002328000 • pfff 57994292 15 • Legal 1:1 LT COUNTRY LANE EST • Owner Name: ANGELL TILDEN G TE • OwnedAddress 1: AN DEN G ESTATE • OwnedAddress 2, • Owned ss 3: 219 FARMLAND RD • State Z. MOCKSVILLE ,NC 27028 - 0000 • Land Value: $7,500.00 http://67.96.98.3/scripts/esrimap. dll?Name • Assessed Acres: 1 • Deed Book/Page: 0015 / 0001 • Deed Date: 1989/08/07 • Sales Price: 00 • Prop ddres 140B0008 • County Zoning: TOWN • Census Code: •ode: • Fire Distric. OCKSVILLE FIRE • Flood Zone: ZONE • Flood Community. 370308 • Flood Panel.• 0075 C • Flood Map Date: 12-17-1993 Davie sdx&Cmd=PanE&ilayer=Parcels& NE i=) SE .Rig. Map LI Draw L Draw select Boundary F Census Tra City Bound F County Zor Multi Syl F E911 Fire C F Flood Pane F Flood Zone W Parcels (— School Disi Multi Syi Soils Town Zonir Townships Multi Syi Voting Pre( Infrastructu F— Driveways F Rail Lines F— Street Cent F— US/NC Higl Multi Syi Aerial Phot Physical F- Creeks and F E911 Addre (— Fire Depart Schools Draw L MAP Cl. This map is prep; inventory of real I within this jurisdic compiled from re, plats, and other F and data. Users ( hereby notified th aforementioned F information sours consulted for veri information conta map. The Davie ( 2/17/2002 avle ounty, o aro ina pada ata Exp orer Page 1 of 3 Sari a1 Data £ rA p U N. , North Carolina err �a` M1 A� w � a � m a w J J a Adjoining Parcels Displayed Below r - 373342-rM 3739429213 0, 3739MM21 3 7331 23 314 • Parcel ID: 140000007709 • Account Number. -000002144000 • PW 5i'59525544 • Legal 1:35.46 • Owner Name: ANGELL BROTHERS • Owner/Address 1: ANGELL BROTHERS • OwnerlAddress 2: • OwnerlAddress 3. 219 FARMLAND RD • City,State Zip: MOCKSVILLE ,NC 27028 - 0000 • Land Value: $225,460.00 • Building Value: $0.00 • Out Building/Extra Features Value: $0.00 • Assessed Value. $225,460.00 k • Assessed Acres: 35.46 • Deed Book/Page: 00194 / 0703 • Deed Date: 1997/05/19 • Sales Price: $0.00 • Property Address. • County Zoning: TOWN • Census Code. • City Code: • Fire District MOCKSVILLE FIRE • Flood Zone: ZON E X • Flood Community. 370308 • Flood Panel. 0075 C • Flood Map Date: 12-17-1993 • Soit • Township: MOCKSVILLE • Town Zoning. • Voting Precinct. N MOCKSVILLE - COU • School District: MOCKSVILLE • Assessed Acres: 1 • Deed Book/Page: 00162 / 0671 View Map ,. . re This map is prepared for the inventory of real property foi within this jurisdiction, and is compiled from recorded dee plats, and other public recor and data. Users of this map hereby notified that the aforementioned public prima information sources should i consulted for verification oft information contained on thi map. The Davie County, mapping, and software companies assume no legal responsibility for the informa contained on this map or in website. Data Effective Date: 12/19/2001 5:28:08 J Current Date: 2/17/2002 Time: 10:36:14 PM http://67.96.98.3/scripts/esrimap. dl l?name=Davie_sdx&Cmd=ShowAdjoiners&ParcelKey... 2/17/2002 Davie County, Ngrrh Carolina Spatial Data Explorer 1 of 3 r 3739427121 http://67.96.98.3/scripts/esrimap.dil?nam... s=Multi +Symbol&dlayer=2&dla3ter= l &dlayer=0 Adjoining Parcels Displayed Below 373942913 N" View Map This map is prepared for tl inventory of real property h within this jurisdiction, and compiled from recorded de plats, and other public rec< and data. Users of this ma hereby notified that the aforementioned public prin information sources shouk consulted for verification o information contained on tl map. The Davie County, mapping, and software companies assume no leg; responsibility for the inforn contained on this map or it website. Data Effective Date: 12/19/2001 5:28:08 Current Date: 2/18/200; Time: 7:46:17 AM 2/18/2002 7:45 AM DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002723 Tax PIN/EH #: 5739-51-0949 Billed To: Jennifer Harbin Subdivision Info: Country Lane Estates Lot # 2 Reference Name: Location/Address: Country Lane -27028 ? Proposed Facility: Residence Property Size: see map Date Evaluated: L i?, - � Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group C - fC G Consistence Structure Mineralogy HORIZON II DEPTH �� 3 Texture group Consistence /7 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: / J LONG-TERM ACCEPTANCE RATE: 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) ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■M■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ M iiiiiiiiiiiiMENNENiiiiiiMENNENiiiii ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■/A7■■■■■■■■�■■■■■■ ■■■■■■■■■LiJiJY■i■�I■■il■■■V V■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■■■■■■■�■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ mom ENE ■■■ ■■■ ■■■ ti :;y'.,.r i :t,.., ... :: i`+:✓ 'v ..t..,164: -'w r.. '' �"tj}�A: t' L'-- - DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a ' Sanitary, Sewage Systems o Permit Number Name Date NO Location Z!::,:Z ea4ma� a. Subdivision Name �4a,� �s % Lot No. Sec. or Block No. Lot Size House r Mobile Home _- Business Speculation No. Bedrooms -- No. Baths No. in Family ~i _ Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO ❑ Auto Wash Ma thine YES ❑ NO ❑ Type Water Supply *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. WAI !- 4 Improvements permit by *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985. Final Installation Diagram: System Installed by Certificate of Completion Date 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. -,� DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND . CERTIFICATE OF COMPLETION *WOTE: Issued in Compliance With Article I I of G.S. Chapter 130a Sanitary, Sewage Systems Permit Number u .dameDate �7- - 6 74' 3 far % Location�,: Subdivision Name Lot No. Sec. or Block No. Lot Size House t/" Mobile Home _ Business __ Speculation No. Bedrooms No. Baths — 4 Y-2 No. in Family >-/' — Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO ❑ ,,�1 Auto Wash Ma.hine YES ❑ NO ❑ / r" - /C� G�� / T � �� Type Water Supply _ *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. r - Improvements permit by./—Z // *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985. Final Installation Diagram: r, r System Installed by Certificate of Completion Date "The signing of this certificate shall indicate that the system described above has been installed- in compliance with the standards set forth in the above regulation, but, shall in NO way be taken as a guarantee that,the system will function satisfactorily for any given period of time. ' DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name v..,U%r7 %� �:l.e i Date �C= — — `� s :ir. S! 26 Location Subdivision Namef �f .f ^, f ��c Lot No. _ Sec. or Block No. 11- Lot Size d c1, House `"� Mobile Home _ Business __ Speculation No. Bedrooms � No. Baths � %�- No. in Family _ Garbage Disposal YES E— NO p Specifications for System: 1 6e 1-) `1`a,, L= -- Auto Dish Washer YES -E NO .E] Auto Wash Machine YES B" NO p Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. Improvements permit by *Contact a representative of the Davie County Health Department or final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone urn r: 704-634-5985. Final Installation Diagram: System stilled by F f— '�f' Certificate of Completion �� <"� Date *The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 1. Permit Requested By 2. Address 3 osr j < S T 3. Property Owner if Different than Above. Address T Home Phone 63y- �7ry Business Phone 4. Permit To: a) Install 'Alter Repair b) Privy Conventional er6er Type Ground Absorption c) Sub -Division ear%T Ar Sec. Lot No. Z 5. System used to serve what type facility: House -*en --Mobile Home Business IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions Bed Rooms 3 Bath Rooms Z Y Z Den w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water -using fixtures: commodes urinals_ lavatory -3 showers 3 garbage disposal washing machine dishwasher sinks 3 8. a) Type water supply: Public "� Private Community b) Has the water supply system been approved? Yes -i No 9. a) Property Dimensions . 97¢ Q.« b) Land area designated to building site c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Ot'-" What type? This is to certify that the -information isco ct to t st m nowledge. /fl ZZ —S-/ oo Date Owner Sig t re OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: " H- z DCHD (6-82) DAVIT: COUiMY HEALTH DEPAMMUT PERCOLATION TEST RESULTS DATE /0-17-79 NA.n1E Country Lane Estates Section II LOCATION Off Country Lane Country Lane Estates Section II Lot # 2 Lot Size: 0.976 Acre FINDINGS: HOLE 140. 'fie ,r Y -%sT r,, , ,c C, �� II 1 I1, bOYh� '—�! `30 , � S� wuS �i� �tul.•1'.cS 2 'I,� �' II -� o hc�. 4 5 avCAQ Eg nClAe s 110 ti.1• -J\ 6 LOT DIAGAW. 1 407- VV",? C0: MEI1TS cv, L r ,br,wulN I10 LA I ra C o" Jes.Ce •f Ftx. A -b LDlwz 0.4174b %P;.7 4, a 6/" 13. g'.30 v J /�V STATEMENT •-DAVIE' COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION 210 HOSPITAL STREET P. 0. BOX 665 MOCKSVILLE, NORTH CAROLINA 27028 (704) 634-5985 DATE /o' 2.2-jos/ 1�A� ; D �vzA2f L DETACH AND MAIL WITH YOUR CHECK. I YOUR CANCELLED CHECK IS YOUR RECEIPT.