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2257 E US Hwy 64 - ClubhouseAppraisal Card VNaw All Cards Ne3d Card DAVIE COUNTY. NC 1 N HI] 1:SS:lI PN LUE DOG HOLDINGS LLC R ,n/Ap—1 Norm:—1HPP{M l 35] E US HWY 61 PLAT: / UNIQ 0 19I 306111 D230 -P29 M NO: 576602)464 COUNTY TAX (100), FIXE TAX (100) 3000( CARD NO. 1 or 2 al Yaer. 201] Taz Y_, 203] 163.285 AC HWY 61 165.]80 AC SRC InryaLOon COW—.. DETAIL MARKET VALUE DEPRECIA OM CORRELATION OF VALUE unNDon-4 1 2 0, 1 EOBS ELw1Nnt 0.1 - — 6. I 9]6 99 ub HN System - z CRT 6 1 sten-ard D. Neon Gra-« 5. F EN. D Arta %30(2EEN BASE RATE 0.011 EY0 AYB —CE TO IWRNET a WND - 0] 78 Fnern FIDer SHInORlardle @4 01 5 3]8 99 %X10( % 1%9 %9 %GOOD m..UILD[N6 VLLUE - CARD ..._,. WUIs u 21 TYPE: Counts CMD n OJ STYLE: 1 • /.0 Story fnnstruGM-5 uno �anspw.mn `IARKEF LAND VALUE - CARD rLL PRESENT USE VALUE - PARCEL AL VALUE DEFERRED - PARCEL TA LE VALUE -PARCEL BUILDING AREA NOTES W CLUB 36 H S INDICATE 2 976 97 S- 1 2 0, 1 976 99 9]6 99 53 56 I 9]6 99 52 CRT 6 1 76 97 5 %30(2EEN LFENCE E 1 1 4 4,2 1 _ 982 9 967 98 11 21E I, 611E 8 2 2,21 1 2,2 100 1 _ _ 001 973 9] 611E 21 E 4 2 1,2 1 986 9 2 300(E 1 4 13 1 1 _ 966 9 996 99 2E 4 )ON_ DERV /ILNDICOND I RF AC LC TO LAND I TOTAL I UNIT LAND UNF LAND I OVERR[DE I LAND Owner: BLUE DOG HOLDINGS LLC http://maps.daviecountync.govlitsnetlAppraisalCard.aspx?idP=1222214&Action=Auto Page 1 of 1 Parcel: 36-000-00-054.0 1/24/2017 tr.. �LcQr„�ow �1►wQ �cn.� m P.1. i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900158 Billed To: Richard Hendricks Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5768-02-7464 Subdivision Info: Hickory Hill Lot # Location/Address: US Highway 64 E-27028 Property Size: see map ATC Number: 3592 **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 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 1# #People #Bedrooms j— #Baths c?. S� Dishwasher: ?!r Garbage Disposal: ❑ Washing Machine,;2r Basement w/Plumbing:00" Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply � Design Wastewater Flow (GPD) —.9yD Site: New Repair ❑ System Specifications: Tank Size,GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width _jj�:"Rock Depth 1,,2 Linear Ft�O0 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. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** �n r Environmental Health Specialist's Signature: Date: /0-1? 1�77 DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900158 Tax PIN/EH #: 5768-02-7464 Billed To: Richard Hendricks Subdivision Info: Hickory Hill Lot # Reference Name: Location/Address: US Highway 64 E-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3592 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: fP --3� 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: Q /40Y -TX/,' Environmental Health Specialist's Signature: 4r Z/ Date: I—P.;2 —02S. , DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environlnentafffeaith Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Referito the INFORMATION BULLETIN for instructions. 1. Name to be Billed Contact Person Mailing Address [ 4tyoc llye.q L/V Home Phone �)Qy/ 7� 2o City/State/ZIP y dGL�S1„`�/C� �. ��d�� Business Phone /Q / -/:w 2. Name on Permit/ATC if Different than Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation El Improvement Permit/ATC ❑ Both 4. System to Service: R House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: ❑ Conventional ❑ conventional modified) ❑ innovative 6. If Residence: #People / It Bedrooms o� # Bathrooms GDishwasher ❑Garbage Disposal Q14shing Machine OBasement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type It People It Sinks It Commodes # Showers # Urinals It Water Coolers IF FOODSERVICE:. #Seeats Estimated Water Usage (gallons per day) 8. Type of water supply: 9-County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑fii6 ii 3t If yes, what type? -: ***IMPORTAArP** CLIENTS MUST CObIPLETE TIIE REQUIRED PROPERTY INFORMA'T'ION REQUESTED BELOW. Either a PLAT or SITE PLAN dIUSTBESUBAMTTED by the client with THIS APPLICATION. Property Dimensions: rf_'U Z / y Tax Officc PIN: # Property Address: Road Name City/Zip %VOcFJ., If in a Subdivision provide information, as follows: Name: .� Fv t U_', f - Section: Block: Lot: WRITE DIRECTIONS (from Mo&sville) to PROPE'RTN': 6¢S7— a.-L T - Date home corners flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permil(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 ani responsible for all charges incru•red 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 SIGNATURE X 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). Sign given Revised DCIiD (05/03 Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. 0 O �O Invoice No. _V DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APIPLICANT INFORMATION Account M 989900158 Billed To: Richard Hendricks Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH M 5768-02-7464 Subdivision Info: Hickory Hill Lot # Location/Address: US Highway 64 E-27028 Property Size: see map Date Evaluated: AD �rzof Water Supply: On -Site Well Community Public Evaluation By: Auger Boringy Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L Sloe % ` HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence 7 Structure i 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: REMARKS: EVALUATION BY:U� OTHER(S) PRESENT: «C 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) ■ ■ ■ ■ ■ ■ ■■■S■ ■■■■■ ■NONE ■■■■■ ■E■E■ ■E■■■ ■■■E■ ■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■NOON■■r.■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ UMMMMEM IMMENSE MENNENiiiiiiMENEM ■■■■■■■■■a■■■■■■■■■■■■Mie■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ MESON ■■■■I MEMO ■MM■■ ■MMM■ ■■■■■ ■M■■■ ■■M■■ MOONS MEMOS, NONE ■■■■■ ■■■■■ ■MMM■ ■ ■ i 9ma ) a (+eaeN � RoSa�At � 6370 � (3z.e1N 19A t4iA 9250 4° one 0-W j (—A) d $ ((11N B10D ® 9 2194 166 em9 z.aa 27388 121?) a ,1 d ars ......3. zp n.16A) 8 seze 3 an rasa 11 6865 8 0888 '9 s, aen a g 4811 9883 (14" s sslz 7 5m s7n zm2 g a k Bno (2aa) a' "^b'a maz b D7A) 0817 6 @ (210A) .. 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A9 1393 331c 6371 .286 1 w 7350 a n s204 �t w9 oz3125 w ffi` , it '1°' stt4' 7166 5121 tm b? 31'2 ® 3089 a .. a. tm 0087 81088 .' � 7fIWl. v° 6053 tS 9098 w,a9t - � ° �m 4� .49os gmu� sels� ton (4.98N 9 'tom 4 'A ,a ,00 P1i0A._. 3849 �3e35J v g 89roRl 5 a5 • 5664 7952 8971 ff 9982 n� s6e ffi • 4e27 SEW Rpw . .m p,�aeo ze53 3:56 �) 8 716 .4767 0760 m 8772 9785 0¢ ye $ Q 7780 `d mit 46 87 8897 .ra !0 nal 61st 9 WA) 1401 91011 2000 2090 3090 5000 5999 ]909 8909 9908 9999 0998 2927 -'HICKORY TREE ROAD' - — -- O79 7 im tm tm tm tm tm 1796 2798 3796 4796 6794 @ 8781€u 7794 {' 8793 9792€ 0792 . 179z (5189N 38181A ofn 7 seas (iiis) 9 urs 22 OaA 266 +g e 48R 5 n® p 7852 d586 7456 6663 � G 35, 42. "a 6185 56 8026 X01 7813 (2481A) S1J) - 7eoe wio a )SM ]328 � 9580 p wm 178 Pl70 ri137 8 � a to ((735A7 7941 Y BB89 E 0828 c fi m � 164 9761 Q (4721A) iaBB oszo 4n , 4-e32e 9402 (ttt � s 6358 (111A) 6253 d 8 6142 & 8 . 6046 3 6931 3 W21 6 (1609A) 2777 `m a 9 AUTHORIZATION NO: 1 3 0 6 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permifttee's P.O. Box 848 Name: �'� ���'' �,ni ,�' t { Mocksville, NC 27028 Subdivision Name: .^1f /+ _eyC 1-7,,6;;L Phone #: 704-634-8760 Directions to property: �� y C Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - - Road Name: At I ^ F Zip: Z 7y a cS" **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 Pernuts. (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 Gj / e IS VALID FOR A PERIOD OF FIVE YEARS. �1VJV 1KV1VN1C1V 1 HL r1CHL 1 r1 JYCl.1HL131 LHIC IJJ UL'U - _qa 1 3 0 6 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION FTRMITS PROPERTY INFORMATION Permittee.'- s Name: j_.} �.. .: , I I (',� (' 1 a Subdivision Name: '?, D•'~�y ocK 2 702 Directions to property: #" tl Section: Lot: IMPROVEMENT _ PERMIT Tax Office PIN:# Road Name: 1. r%t Zip: **NOTE** This Improvement Permit DOES NOT authorize the constriction 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 1F SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE O Ffrc # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes o LOT SIZE r I TYPE WATER SUPPLY C(nV` DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE I l i! I SYSTEM SPECIFICATIONS: TANK SIZE L o 0 D GAL. PUMP TANK GAL. TRENCH WIDTH 3 L ROCK DEPTH 12 LINEAR Fr. ' a REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT �4 �s �� 70 "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 THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT /� /`� � � SYSTEM INSTALLED BY: 46 ��Q 1 z419- - u+,)e-S, Ra-„�Go 1-3 zo AUTHORIZATION NO. UP OPERATION PERMIT BY: / DATE: S "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 05/96 (Revised) i - DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Perml t e's t Name: Subdivision Name:"' tic k Directions to property: Section: Lot: IMPROVEMENT 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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE c)f f r(- # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes d No LOT SIZE r C< < TYPE WATER SUPPLY �(r"�'� DESIGN WASTEWATER FLOW (GPD) NEW SITE.—REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE L"—() GAL. PUMP TANK GAL. TRENCH WIDTH J �' ROCK DEPTH 12• iINEAR FT.' O OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT 70 75 "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 THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY:`� �l. D <-Jij) o' 7JIS S' AUTHORIZATION NO. %/ OPERATION PERMIT BY: ( : ' = _ / DATE: J "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 05/96 (Revised) ': SEL LL Oct QC t0 ,.$i,, ,.,3as,. %C o«r o.z9 j I HIM d »2 Cbz Atte a1L ; i " io £8l ♦ �i--, 1 i t � w". lel zooz 1 1l$i BEI � !. �r 9A1ti , � _� t � sad I� e�., •: t ° �� - � �', . a�� AAL ..,�', -� � „� �! �.� —♦:" i r +� 1� zt 7C L 9Lsnzz tt ► BLi 19ZZ1 ,.� _Ov-1 S w � k1 7 .:♦1 SSZZ �. 1 „r ZM + 89Z S6Z < IC t 66't In } . /H , i e sa r i 1 _ / SBf wN +ey. 4Og s..w w £99 6G " ,,,, _ '. 486 ' "'"l✓ '� J„ i,,,� a. Viz; 9 LE "' pp i- §fC t ..,� ♦ 1- %;7-saa . r DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION W -S.? APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) DIRECTIONS TO SITE 4$1-e - 6e, ONE NUMBER BDIVISION NAME LOT # DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER %ia !WJ/Wf TYPE FACILITY ! NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY CQa,-r SPECIFY PROBLEM OCCURRING i e4l / lehxo-d ka&Z' y6 141'a -W iQ_- DATE REQUESTED T" �' �� INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge,d th t I understand I am responsible r all charges incurred fr this application. SIGNATURE OF OWNER OR AUTHORIZED AGEN ane4 Rev. 1/93 Stone Land Surveying Co. P. 0. Box 307 Mocksville, NC 27028 Cart Path 57 • • 30 •• • GRAPHIC Richard Hendricks JOB NO.13403 Hickory Hill Club House Part of Hickory Hill Golf Club SCALE 1 " = 80' Field Work Date 10-07-2003 Date of Plot Revisions THIS PLAT IS NOT A CERTIFIED COPY ISSUANCE FOR ILLUSTRATION L -PURPOSES ONLY