154 James Rd 1 1.y 'L S sw :air. F yy y: Y f.. r n. i v. W a_• a: S f. t !
t-
AUTHOR14ATION NO:4 1509 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee'~ P.O.Box 848 \
11
Name: Mocksville,NC 27028 Subdivision Name: ../i711M05ILs
Phone# 336-751-8760
Directions to property: (,.,)q Ccyl `'�1 Section: Lot:
{ p 1 AUTHORIZATION FOR
r: ILLX �` C��► i) N LLF i WASTEWATER Tax Office PIN:# 0�0 . _ /
` /} , SYSTEM CONSTRUCTION f
,�} Road Name:. l`� Zip:
**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 ith Article 1 1,,6f 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.
ErMRONMEK-rot HEAMBPEtJAWT, DATt ISS ED
� � �nrf.� �z i7� ip �t 'i`m' � �' ♦. L. a `i i yriu�. � .. _ .. '' i `i t {: .y: `"^' �.'_,.
'.. �J
R DAVIE COUNTY HEALTH DEPARTMENT . ''
IMPRO EMENT AND OPERATION PERMITS PROPERTY INFORMATION
Per!6t
Name. 1►f1 � AMSubdivision Name JNEA
i
Directions to property:I t '`� �"t�� � i Section: Lot:
�I. IMPROVEMENT
V- 1 1'}c V') tJ^+J� [. Q ► PERMIT Tax Office PIN:
L, Road Name: Zip:27
d 0
**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
constructionrnstallation of a system or the issuance of a building permit.
(In compliance with Article I j 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
E1IVIRON ��L HEALTH SP C ALIST, DA IS UED SYSTEM CONTRACTOR MUST SEE TIM PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS Z- #OCCUPANTS GARBAGE DISPOSAL:Yes or Q"o
COMMERCIAL SPECIFICATION: FACILITY TYPE y #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:Yes or No
1 'l GOO T DESIGN WASTEWATER FLOW(GPD)��NEW SITE—V REPAIR SITE
LOT SIZE C��TYPE WATER SUPPLY �
SYSTEM SPECIFICATIONS: TANK SIZE 000GAL. PUMP TANK GAL. TRENCH WIDTH "'`�'/ROCK DEPTH 14 tLINEAR FT. {
OTHER L'SI� rJ
p
REQUIRED SITE MODIFICATIONS/CONDITIONS: 11J,STAt.�. QA C,04TOUK-4 K—C,CjT" IllI Paoray LIr1c,
tfL
IMPROVEMENT PERMIT LAYOUT
100 r lot
JOD �
T
YJ ,
1/0
**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 (336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: S ZA Mdo— U,is pi
USCcQ ij/GKJ K W( L-f-
��.fJ�i-h•to Ate'
tA
AUTHORIZATION NO./'45") OPERATION PERMIT BY: DATE: ' 477
**THE ISSUANCE OF THIS OPERATION PERMITSHALL 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)
F�
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
~, T Davie County Health Department O M
Environmental Health Section 4
P. O. Box 665
R
Mocksville, NC 27028 JUL 17 I��o ►
U�
1. Application/Permit Requested By �v/1�Z; � I CS "wr+' �• .
Mailing Address—1 _ 0X q-? ( Home Ph ne
liroC kfV,'46E: �,C 2- 76 Business Phone
2. Name on Permit if Different than Above P12 � �S�
3. Application for: a General Evaluation UJ'Septic Tank Installation Permit
4. System to Serve: douse ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
7,y,1 �' 1 '
5. If house, mobile home: Subdivision Section Lot # y
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms C3-Washing Machine
No. of Bathrooms Cl-Dishwasher
Dwelling Dimensions �� /l �{ 2 R /G ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type ,f
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: (5 Public ❑ Private ❑ Community
8. Property Dimensions 12 VY 3 97 X 95-y- 3 9 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 1111-116--
If
-WoIf yes, what type?
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: S ��, ,c NA fz cle-
R4 - 7o F'62k Y-(,
till
N_
�-:d//
G 0 %a 0-64MLc5 ocd_ p"
• �o oAt y, 61
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.y ��2 Z ��
DATE ATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 1. I OWN the property. ❑ 2. I DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
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 said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD(1/93)
Jame,w Wilson Pro Y aDDrored the final plot for the certify that the map or plot wto
party SubdiviOion.
is affixed meets all statutory rc
' Date Choirrtton,County Plonniny Board
'
Date' Review Offi.
£/p r
See p/ tot tL
n of Bo ?
£/p N \ 8S 00, Nip ea'6, w ok 6 . E:F \ D.& / 8/0 age 9e 179
81 urn
s
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ci 30r£ ❑
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or –ti
180 `'r
1 . 00 Acr N
1 . 00 Acre A e
� I I
1 qi
l
iasion w
o �
i
EIP o NIP NIP
NIP �� W
N 97o.46' 0 0 0
Point ° 27.44' 1042.91' W
W 8�--__W pO_�w N 89° 24' yy Point 99.93 in 55.25' 78.62'
Total nt
N 88° 13' S0" w 155.18' Point 5 81°50'25 W poi — w
—__ 0.35' w —w a
pprox. I-'c ion 6" water
Notes
1• Average lot size to R/w is TOocre.
2. Property is not in a Flood Hazard Area.
3, All lots are to be served by individual sewage facilities. North Carolina,
4, All lots are to be served b Pubric of the cZ; — Co-r.=. 1,a Notary 1,C.
y county water. aunty and stat.afonaoid aerti/y that Ray cat.a,certify
5• Property is Zoned R/A C.Ray Cates-°registered land surveyor, SUPervision from an oc
personally OPPeand before me on this day and recorded in Book.Pag.
6• Minimum setbacks Front 40' 0`t e° `'d "d the exK�lan of the foregoing matti,,mt. arena a�Cleony inc
my hood and official"*I,this thePage that th•
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC
Y Davie County Health Department n
Environmental Health Section V
P.O. Box 848 D
Mocksville,NC 27028 SEPI 1 1997
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed r.l '!l-� , W it-<DA Contact Person Il k- JC: At-}Z-LAA�
Mailing Addressf f¢ �A.y�F� ,�D Home Phone 'Vol ��?R- 2J 70
City/State/Zip AP.MWtAe , Me- -2--7006 Business Phone�U�
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: Vite Evaluation [ ]Improvement Permit&ATC [ ]Both
4. System to Serve:. [Wuse [ ]Mobile Home [ ]Business [ ]Industry [ ]Other
5. If Residence: #People #Bedrooms #Bathrooms [ ]Dishwasher[ ]Garbage Disposal
[ ]Washing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing
6. If Business/Other: Specify type #People #Sinks #Commodes
#Showers #Urinals #Water Coolers
If Foodservice:#Seats Estimated Water Usage(gallons per day)
7. Type of water supply: County/City [ ]Well [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes uAo 3 LU?S
If yes,what type?
EITHER A PLAT OR SITE PLAN
_
PROPERTY INFORMATION REQUIRED:***IMPORTANT**KX4WT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: 3 ,�(���c' /7< TE DIRE�ONS(fromx>!�Nyale)TO PROPERTY-
-57 CC7 w /Z ��
j Tax Office PIN: # � 5"y °�-'"
Property Address: Road Name �.r1 tiiE= s 1-6),4 O � �fL&!ZEti--� � �?
'I City/Zip /� 1✓�Xl'l.c.G Al,
h If in Subdivision provide information,as follows:
Name: P •%/I�/mss IN bt�.Lsa ✓f'�' ;��y
#:] .
Section: Lot '
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits)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 -ZAh,uE5k 114- 1&J/LC n to conduct all testing pr cedures as necessary to determine the site suitability.
DATE 09 -09-.19 SIGNATURE
Revised DCHD(06-96)
THIS AREA MAY BE USED FOR bRAWINC YOUR SITE PLAN:
;r
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT 1
Soil/Site Evaluation
APPLICANT'S NAME v4�1G5 V��t-�� DATE EVALUATED n
PROPOSED FACILITY hr't/ PROPERTY SIZE ` -Gee
SUBDIVISION ROAD NAME
Water Supply: On-Site Well Community Public c_�
Evaluation By: Auger Boring ✓ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position L
Slope% 47o
HORIZON I DEPTH D
Texture groupL
Consistence
Structure k
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure S3 k
Mineralogy 1.
HORIZON III DEPTH '4o-q2
Texture group
Consistence ; S
Structure
Mineralogy `
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION 1 PS
LONG-TERM ACCEPTANCE RATE 0.41 rj•
SITE CLASSIFICATION: f S EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS: � C kY
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(O1-90)
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�,
The under�igned he�eby xknowledge that I om (we are) the ownera of the
property shown and deacribed heroon, which ia lxoted in the aubdiviaion
juri�ction of Davie County ond thot I heroby adopt thia plon of
subdivision with my (our) froe cons�nt, eatobliah minimum building
setbock linee, and dedicate oil atreeta. olleya. waiks, parka, and other
sites and eosements to public or privote use aa noted.
aigned
Date
signed
Date
Owner :
Jomes W. wlson
114 James Rd.
Advonce, N.C. 27006
NrM Cw�r. O�a�r• l e qaesry
NMe d M. Coiw�r o�M ]IM� e/a�M �+IM� 1Mt
wr M
aalwwb/y�d tl» wa� d Ur taqeiq M6an�iR.
r�r.. �y �d .r ernasi ..�i. u�. w da
d . �i ��
�6K C�e SfAI�
Morner rt�uc
1
I
$Q�. P/Q f eo pt ?
Eay °k 6,
D,B �8 �a%�� ° 17g
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\ s 49, �� 2•z�.
i
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Parcel 62 �i �
D.B. Webb :r �
� � I
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�
GRAPHIC SCALE — FEET �N
�
R/W w cloime� bY c� - y'r
the N.C�FGy►�� ����� • a'-
_ l �
El� � NIP O O
0
�
N 27.44' •-�i 42.91 ' 99.93' "' S5.25' ;
� N'86• 4d' W�'�N�89° 24' W � N 88° 13' S0" W 155.18'
_ — — 7otal 70.35' ` �29
"�_ —�_
LEGEND
R/W - Rlyht-ot-way E, - C e n t� r L I n e
� - � � R ve� °r�,� Notes :
� Potnt �_���' 1. Minimum lot size is 1.00 Acre
qr - �°""''t' ►�°"""'°"t �_�� 2. P r o e i s n o t in o Fl o o d H a z cr d Ar e a.
N I P - N� w I r o n P l a c � d P� Y
C�ri{}�ioal� oj Appra�si o Ai�af� (on-aib) Sw�g� Dtspoaal Syslena�
I Mnby cerWy that th� • County Healtfi D�portment hw waluot�d
th. s�ed�on .e+tw.d w. wr,o� P.op.riy
rlth nspsct to crit�rio �ronditions atoblish�d by stat� bw or
P►cmulyoted tMr�und�r the sonw ia tound to cor�py with aueh
criterio ond oopdilioew w found in auoh woluotion. For d�taib
of tNe evaluolion and for� 6mitatiaro sw tM xritt�n roport on flh
et the sdd D�portm�nt. j
IMPORfAKT NOTICE: THIS C�RTiFK'.ATE OOES NOT CONS[IiUTE A PERMR OR
R
APPROVAL OF INDNIDIlAL lbTS MI SAID SUBDMSION FOR MISTALUTION
OF SEWAOE FACIL�TIES.
Dota
y ' County ►NeRh Olficiot
1
,
Stot• of NeptA Coreilna
Ceunty of
1, , R�vl�w Offic�r ef Csunty, c�►tify that fh•
mop or plat�te whlcA tAls c�ritticotlen is offlx�d m��f•
all stof,utory r�qulr�n�nts tor r�cordinp.
Det• R�vl�r Offic�r
a� \
J
;� \
�
78 Os
��
�1
m `'�
O oo � Wm3�
N �, . �. c! cD
R1 O� � 7 O� N_
� U o �G � CN7� � p�
c.+
N N ��'' o � t�
_ m � � <D �! p
� � I O�tJ7
J <O O�
J
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I
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N� � — d
J W ames R' .
— o �T
�8.62� W — � � 161 �
v�'� � • •
S g��s� � �_ —
_� '�
� f�
�
P/L - Pr oPa► t y � I �• tt - Rod�u, 3. All lots are to be served by indivduol sewoge focilities. �' c01O�1°� �01"'�'• 4°�°�'
C A- Controlled Aoe�sa �- CAord datance Pub�e er tl» Canqr wM lls� daMdd wINY 1Mt
�_ Re�r�roresd �on«�t� Pfps P 0- Part of 4. All lots are to be served by county woter. c. �, cec., e�.�►.a�.e �.�e .�.r.ye.,
CW - Ca*u� ed AI�lol PIp� -� E� vM��lb wM«�d bdoru nn on ur� d4r wid
OCP- C �d Pfe�tiC Plp� ����,� 5. Property is Zoned R/A �ro.�d +ti....o� ae +ti. �o r.dv�.
_� �� �''°°' � 6. Minimum setbacks Front 40' �M "9� hai° �d �,'o�' � � �
-x- �''�'�0� -s- 5'r°' u�° Side 25'
Rear 40' s�x «+ sw�r
7. Iron stvkes at all comers, except as shown on plat. ��+' �
NOTE : TNIS PLAT IS SU9JEGT TO ANY EASEIENTS, �GREEIENTS, OR $. TOtO� area = 3.00 Acres by d.R1.d.
RICaNTS Of INAY OF REGd10 PRldi TO THE DATE OF TNIS PLAT. g, Porcel number shown refer to Davie County Tax Mop H-7 ��M���~
10. All lots ore to served with underground utilites from RW to dwellings.
TMIt CUNVEY li CUldECT TO ANY f/1GTt 1NAT INY !E DIiCLOiED !Y A FULL
MID ALGWIATE T17LE i[Mpl, MOT fUM11iM[p TO K K Gf TM�i OATE.
i. c. rtay coe... wtly thac w. poe .o. era.n �.+d.. ny
sup�rvldon t�orn an a�.tud w�y mad� u�d�r ^hr r�pv�A�la+ idwd dwvlptlon
r.ea�a.a r sook . Pep. ..ca) (a+w}, n�ec el�. ba,daw not
r�rv�y�d an al�ery Y�dle�bd a� dra�n iren� Monneuon tound tn Book � naR�d
ra�. • nwc nn �vae a p.d� a. �at.e r,:,o.000: nae vrs
Plec ra p.ya.a In eeoe.d.w. .nh cs. a7-x m arwia.a. ww�... rry af¢nal
�. e�yf�dallem m�ib.. ana ..e�
y� 5th�, d August �.1997
Seof or 5tamp
s�.r.yo.
2623
R�9Wdb^ fhMnb�►
�
\ �635
Location Mop n.t.s.
Th• forapolnp c�rtificota
B�Xby
5�/
: -_- � �.
- ` �
�
C'�
0
S.R. 161$ ! .
.y SR �s��
( HERE G I VE NAA�E
ANO OfFICIAL TITLE Of TH£ OFfICER SIGNING
is c�rtified
THE CERTIFICATE PASSED UPON)
to be correct.
This doy of , 19_
Probat• fe• poid.
Hanry Shora. R�pist�r of De�ds
by
DEPUTY-ASSISTANT
Filad for rapistrotion ot o'clock
, 19 and record�d
in Plot Book , Pop• .
Hanry SAora, Repist�r of De�ds
Filinq Fee Paid
by `
DfPUTY-ASSISTANT
a
I hereby c�rtify that the suDdivision piot shown hereon hos
b�en found to comply with the County Subdivlslon Reyulotions,
with the exception of such varioncas, If any, os noted in th�
minutes oi the Planninp Boord cnd thot ft has be�n opproved for
recordinp in tha office of tha R�piat�r of D�eda. It is her�by
noted that such approvol for recordotlon do�s not include
opprovol to fnstall and utilize sonitory faciliti�s nor does it
includs approvafi fior fhe constructlon or occupancy of buildinps
or structures.
Dota Dirac�or, Davie County Plonninp Deportment
Division of
M
James �'. Wilson �'roperty
See Deed Book 181. Page 149
Portion of Lot 3, C. Holt Howell Property, See Plat Book 6r Page 119
Part of Parcel 64.01, Dwie County Tax Map H-7
SCALE TOWNSHIP COUNTY SUTE DATE
1" = 60' Shady Grove Davie North Corolina 09-05-1997
C. Ray Cates
SURVEYED: 1 19 Depot Street � N0.
CRC Mocksville, NC 27028 �hUP N0.
�PED: P h o n e ( 704 ) 634-3735 301 iA
CRC Fax ( 704) 634-2750
_.�------_ -
0
' Davie County Health Department
f
andHome Health Agency
EnvironmentafHealth Section
P.O.Box 848/ 210 HosPrraL STREET
COURIER#09-4-06
MocnviLLE,N.C.27028
PHONE:(704)634-8760
September 19, 1997
t.
James W. Wilson
114 James Road
1 Advance, HC 27006
1 Re: 3 Site Evaluations/James Road:
James W. Wilson Property,,
Dear Client(s):
As requested, a representative from this office visited the aforementioned
sites on September 17, 1997. Based upon the information provided on the
application(s) for site evaluation(s) and after the evaluations were completed,
the sites were found to be provisionally suitable for the installation of an'
{ on-site sewage disposal system on each site. ,.
Before any permit(s) can be issued the appropriate application(s) mini be
filled out and the house/mobile home -location(s) staked off.
{ If you have any questions, please feel free to contact this office.
i •,
t
Sin ,
1 ,
Jeff Beauc p, R.S.
Environmental Health Specialist
i
JB/wd
Enclosure(s)
cc: Zoning Office
j