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191 Earl Rd 3avie County, NC _ Tax Parcel Report / p 4 6`�� Friday, September 23, 201 E 1 l ) I i f r- 209 yj 191 ', C I -.1 t tt w 4 175 �f rr !� 'zd .................... f WARNING: THIS IS NOT A SURVEY Parcel Information - j Parcel Number: E30000002001 Township: Clarksville NCPIN Number: 5811860904 Municipality: Account Number: 8302032 Census Tract: 37059-801 Listed Owner 1: SMITH KIMBERLY SLOAN Voting Precinct: CLARKSVILLE Mailing Address 1: - 191 EARL ROAD Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-20 State: NC Zoning Overlay: Zip Code: 27028 Voluntary Ag.District: No Legal Description: 5.129 AC EARL RD TRCT 2 Fire Response District: WILLIAM R.DAVIE Assessed Acreage: . 5.13 Elementary School Zone: WILLIAM R DAVIE Deed Date: 12/2011 Middle School Zone: NORTH DAVIE Deed Book/Page: 2011E1218 Soil Types: MnC2,MnB2,MdD Plat Book: 11 Flood Zone: Plat Page: 132 Watershed Overlay: DAVIE COUNTY Building Value: 123220.00 Outbuilding&Extra 0.00 Freatures Value: Land Value: 35740.00 Total Market Value: 158960.00 Total Assessed Value: 158960.00 4l !� 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, Impfled warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmle]dueto �r County of Davis,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action N`' or arising out of the use or inability to use the GIS data provided by this website. DAME COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 OPERATION PERMIT Account #: 990005971 Tax PINiEH#: EO 00001 Billed To: Sloan Smith Subdivision Info: Reference Name: � LocationiAddress: rl Road-27028 Proposed Facility: Residence Property Size: 5 Acres ATC Number: 6045 **NOTE**The issuance of this Operation Permit 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 NO WAY'be taken as a guarantee that the system will function satisfactorily for any given period of time. System Type; S.T.Manufacturer S�a` Tank Date Tank Size /�d Pump Tank Size. Bedrooms: T System Installed ByOt- V a U i e l�-'d installer# i Ile Date:GPS Coordinate: K er Q 17 1 6P �d DD OW Ce A— Environmental Health Specialist Date: DCHD 11/06(Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street. Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION i '`— Account #: 990005971 Tax PIN/EH#: E00000001 Billed To: Sloan Smith Subdivision Info.',/q/ Reference Na evised 10/07/13 Location/Address: Earl Road-27028 Proposed Facility: esi ence Property Size: 5 Acres ATC Number: 6045 Site Type: XNew ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by'the Davie County Environmental Health Section prior tq issuance of any building permit(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 #Bathrooms_#People ( Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size � Type of Water Supply: WCounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)-31b Tank Size oar GAL.Pump Tank /GAL. Trench Width s Max.Trench Depths Rock Depth_A�� Linear Ft.1/60 Site Modifications/Conditions/Other: adtt(11 0#) Contact the Davie County Environmental Health Section for final inspection of this system between 8:30=9:30a.m.on the day of installation. Telephone#(336)751-8760. Cv -71 In�4 'Environmental Health Specialist Date:101-11301-3 DCHD 11/06(Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH i`tJ P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 Z AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUC Account #: 990005971 Tax PIN/EH#: E00000001 Billed To: Sloan Smith Subdivision Info: Reference Name: Location!Address:' Earl Road-27028 Proposed Facility: Residence PropertyPze: 5 Acres ATC Number. 6045 Site Type: klNew ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior tp issuance of any building permit(s),(in compliance withAArticle 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_ #Bathrooms__2_ People 2 Basement Basement plumbing Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size -j ac ( _ Type of Water Supply: IH.County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) 2y0 Tank Size Ic C-0)GAL.Pump Tank GAL. Trench Width %2 Max.Trench Depth S Rock Depth y _ Linear Ft.306 % Site Modifications/Conditions/Other: Contact the Davie County Environmental Health Section for final inspection of this system between 8:30=9:30a.m.on the day of installation. Telephone#(336)751-8760. f � Environmental Health Specialist Date: o� 0/ DCHD 11/06(Revised) ! ' Davie County Environmental Health • P.O.Box 848/210 Hospital Street Mocksville,'NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990005971 Tax PIN/EH#: E00000001 Billed To: Sloan Smith Subdivision Info: Address: 401 Georgia Road Location/Address: Earl Road-27028 City: Mocksville Property Size: 5 Acres Reference Name: Proposed Facility: Residence **NOTE* This Improvement Permit 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/installatiori 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. Permit Type: 9New ❑Repair ❑Expansionsn Permit Valid for: ;&5 Years ❑No Expiration Residential Specifications: #Bedrooms CQ #Bathrooms oC #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People-#Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): Type of Water Supply: 1gCounty/City ❑Well ❑CommunityWell Site Modifications/Permit Conditions: System Type LTAR Initial Repair 12.Q U.(i Site Plan r G r 1 Environmental Health Specialist AZ Date 0130013 i.p.11-06 / APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Boz 848/210 Hospital Street Mocksville,NC 27028. (336)753-6780/Fax(336)753-1680 Application For: 51 Site Evaluation/Improvement Permit ❑Authorization To Construct(ATC) ❑ Both Type of Application:` Mew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION_BULLETIN for instructions. APPT,TCANT TNFORMATTON Name ,P. sloa, Contact Person )Q;v�A t✓.rctiw�flrC Address qol Borg a d2- Home Phone -33 co 9Z.- City/State/ZIP Mo Vsv%i tQ ivC- Business Phone 334 go R-o!2 99 Email S1oa.-.s►M:Ys. ?�w�..:f.tor•-. Name on Permit/ATC if Different than Above �a►'+e Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name Kl,.A Sr„.k Phone Number C3-309'l0-�39:Z4 Owner's Address yoi 09—J City/State/Zip Macr-5w/(t j jc_ ��z8 Property Address Car y dZd City Ma�ttsv; NC a�Z% Lot Size .5 g e Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: If the answer to any of the following questions is"Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? Yes LO No . Does the site contain jurisdictional wetlands? _Yes %4No Are there any easements or right-of-ways on the site? )QYes No Is the site subject to approval by another public agency? Wes No Will wastewater other than domestic sewage be generated? Yes *o TF RESYDENCR FIT J,OI TT THF,BOX RFLOW #People oZ #Bedrooms oZ #Bathrooms a Garden Tub/Whirlpool ❑Yes o Basement: ❑Yes Wo Basement Plumbing: ❑Yes Wo IF.NON-RRSIDF,NC.E FIT J,OUT THE BOX BFd.,OW Type of Facility/Business Total Square Footage of Building #People # Sinks #,Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: Yconventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ikounty/City.Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑No If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging or st a se/facili locati n,proposed well location and the location of any other amenities. owner's or owner's legal i7ep-rttentative signature Site Revisit Charge Date(s): Client Notification Date: Date EHS: (0�3 Co�3 Sign given ❑Yes ❑No 1 Account# Revised 11/06 Invoice# DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005971 Tax PIN/EH#: e00000020 Billed To: Sloan Smith Subdivision Info: Reference Name: Location/Address: Earl Road-2708 Proposed Facility: Residence Property Size: 5 Acres Date Evaluated: �2 Water Supply: On-Site Well. Community Public Evaluation By: Auger Boring X Pit Cut 913113 FACTORS 1 2 3 4 5 6 7 Landscape position j L Slope%. 'b G "- r° o HORIZON I DEPTH -Y 0-0 0 vq 0—/0 - 2 Texture groupG L e Consistence G Structure 1 116K Mineralogy >- HORIZON H DEPTH +(o 2 Texture group rou C s/C Consistence rg V t% FR ilM 42 Structure w mr, Mineralogy =( LA d HORIZON III DEPTH 1�- Texture group Consistence Structure w � Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS a RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION litrPfS LONG-TERM ACCEPTANCE RATE -3 •Z SITE CLASSIFICATION: EVALUATION BY: ; LONG-TERM ACCEPTANCE RATE: OTHER(S),PRESENT: REMARKS LEGEND LandscaFe 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 1 VFR-Very friable FR-Friable F1-Firm VFI-Very firm EFI-Extremely firm. . 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 lY9SsS . 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 471assification-S(suitable),PS(provisionally suitable),U(unsuitable) rI'AR-Long-term acceptance rate-gal/day/ft2 DCHD 05105(Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■1111■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■111 ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■o■■■■ee■■■■■■■■■■■■■Nils■■■■■■■e■■■s■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■Mile■■■■■■■■■■■■■■e■■■■■■■■■■■ s■■■■■■a■e■■■■a■■■e■■■■■■■■■■■■■■■■■■Mil■■■s■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■Nig■■■■■■■■■e■■■■■■■■■e■■■■■■■ ■■■■■s■■■ae■■■■ti■■■■■■■■■■■■■■■■ I!1!EIS%■■11■■■[:��lli■■■��■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■1\e■■■■■■■■■ti■L.ii■■■■■■■■M�JI>f►/�ili�i■■■I\■■■■■■■e■■■■■■■■ ■■■■■■■■■■■■■■■■��■■■■■rye■■■ri■■e■■■■■e■�i►.�■ted■■■■■n■■■■■■■■■■■s■■■■ ■■■■■■■■■■■■■■■■■►t■■■t;■■■urs■■n■■■■■■■■■�1■■►i■■■■■■u■■■■■■■■■■■■■■■■ ■■■e■■■■■■■■■■■■■■►�■■■■■■�■�e■era■■■■■�e�■■■an■■eel■■■■■■■■■■■■■■■■ ■■■■■■s■■■■■■■■■■■■■■■■■■■et•.,irJE�7■■■■■■�l.�■■■■■■■■11■■■■■■■■■■■■■■■■ MEMNONMWOMME MEMEME MEMEMEMEMNONlF7innomoiMEMNON ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■®■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■sos■■■■■■■■■see■■■■■■■■■■■■■■ ° N .t si4. y r ef� b r Y .�. �y. 1 �,� t � tti ` �, k ', 3 �'Y +�k�s�i M{ y t�Y ill i �� t � t � � �� 4V�� A 4� � � � �k � . �� `� ,�_ c `,� ti a � ,�„ �,,; i �, � �,,� _ ,�, Y A � ._ \ �'^• `'� j • '. ;H - ': � Y . ♦ .. .. V .;. �s�S !�'_ �<f� `. ..* � � � c,:, >' t� " >. � ,'. >a ' g ! _ - .>��. `�� l Appraisal Card Page 1 of 1 DAVIE COUNTY NC - 2/412013 4:35:02 PM MITH KIMBERLY SLOAN DAVIS DANIEL AUSTIN Retum/Appeal Notes: E3-000-00-020-01 RL RD UNIQ ID 968373 SPLIT FROM 1D 5919 301742 ID NO:5811860904 O COUNTY TAX(100),FIRE TAX(100) CARD NO.I of I eval Year:2013 Tax Year:2013 5.129 AC EARL RD TRCT 2 5.129 AC 5.129 AC SRC= raised b 17 on 12/31/2012 02001 BEAR CREEK CHURCH TW-02 C- EX- AT- LAST ACTION 20130111 0CNSTRUCTTON DETAILMARKET VALUE DEPREC!!�AOTAL CORRELATION OF VALUE OTAL POINT VALUE Efl. BASE -1 BUILDING USE MOD Area UAL RATE RCN EYB AYB EDENCE TO ADJUSTMENTS 97 00 %GOOD EPR.BUILDING VALUE-CARD .�. OTAL ADJUSTMENT TYPE:Vacant PR.OB/XF VALUE-CARD • TOTAL QUALITY INDEX STORIES:FACTORRKET LAND VALUE-CARD 35,74 rAAn TAL MARKET VALUE-CARD 35 74 APPRAISED VALUE-GRD 35,74 -C v TOTAL APPRAISED VALUE-PARCEL 35,74Cr' Op TOTAL PRESENT USE VALUE-PARCEL CZ TOTAL VALUE DEFERRED-PARCEL TOTAL TAXABLE VALUE-PARCEL 35,74( PRIOR UILDING VALUE 8XF VALUE ND VALUE RESENT USE VALUE DEFERRED VALUE OTAL VALUE PERMIT CODE I DATE NOTE I NUMBER TAMOUNT OUT:WTRSHD: SALES DATA rECOMB ATE DEED INDICATE SALES R TYPE / PRICE 2 O1 WD A V 37002 011 DC E VHEATED AREA NOTES 2012 SUBAREA UNIT ORIG% SIZE ANN DEP % OB/XF DEPR m GS RPL OD UA ESCRIPTIO T NIT PRICE COND LDG FACT Y RATE V CONDI VALUE TYPE AREA CS OTAL OB XF VALUE 0p REPLACE UBAREA 0 OTALS 0 UILDING DIMENSIONS - N 0 NO INFORMATION 0 IGHEST OTHER ADJUSTMENTS LAND TOTAL NO BEST USE LOCAL FRON DEPTH/MMOD COND AND NOTES OA UNIT LAND UNT TOTAL ADJUSTED LAND LAND SE CODE ZONING TAGE DEPTHSIZE FACT RF AC LC TO OT TYPE PRICE UNITS TYP AD39T UNIT PRICE VALUE NOTES RAL AC 0120 25 0 1.29200.8300 07-05+00+00-05 RG 6,500. 5.12 AC 1.07 6,968.00 3573 crk OTAL MARKET LAND DATA 5.12 - 35,740 OTAL PRESENT USE DATA http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parcel=E30000002001 2/4/2013 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 110 Application For. /Sit.Evaluation/Improvement Permit ❑Authorization To ct(ATC) O th Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modii' ' n of Existing Se 9r Fa i **'IMPORTANT"*THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE < INFORMATION IS PROVIDED_ Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION / Name to be Billed 6J 0 CL J M•-k\ Contact Person JQ n G��1 -N 0 CAS. Billing Address CL, j6 Dad Home Phone City/State/ZIP Business Phone -7[� Name on Permit/ATC ifDifferent than Above ki aamt Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Flagged �02 NOTE: A survey plat or site plan must accompany this application. Included:❑Site Plan>0Plat(to scale) (Permit is valid f r 60 months with site plan,no expiration with plete plat.) Owner's Name Phone Number Owner's Address /7 City/State/Zi `jam Property Address b city ,4) L 21/r P_ Lot Size LJ&re3 Tax PIN# ,j J►j?73 (p FOWW0 Subdivision Name(if applicable) Section/Lot# Directions To Site: 4l ' If the answer to any of the following questions is"yes",supporting documentation must Ife attached. Are there any existing wastewater systems on the site? ❑Yes 500 Does the site contain jurisdictional wetlands? ❑Yes ONo Are there any easements or right-of-ways on the site? Wes❑No Is the site subject to approval by another public agency? S(Yes❑No Will wastewater other than domestic sewage be generated? []Yes 014o IF RESIDENCE FILL OUT THE BO BEL W I I' -IZ Ppr �IN2 W41612,V raw #People bt #Bedrooms #Bathrooms Garden Tub/Whirlpool❑Yeso Basement: ❑Yes Zo Basement Plumbing: ❑Yes 110,10 IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:�County/City Water ❑New Well ❑Existing Well ❑Community Well Do you anticipate additions or exyan"s�n�s of the facility this system is intended to es Yes 11 No If yes,what type? �((. i Jil DDl7lo� C#l�i2tQP Rl1 I► VL�'i L7ad k,-3 This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable la d Hiles. I u erstand thatl am res onsible for the proper identification and labeling of property lines and comers and or i us ili loeati proposed well location and the location of any other amenities. ;11ati,�nPAgd1flla Ties repr gnature Site Revisit Charge Date(s): Client Notification Date: Date EHS: Sign given ❑Yes❑No Account# Ll-7 Revised 11/06 Invoice# 0 1� 4 ' Z6� elp sqyys E►IZ Pa. � y ,.rte C 7