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140 East Rolling Meadow Road Lot 25Davie County. NC Tax Parcel RepoA { Wednesday, December 21. 2016 WARNING: 171(515 NOT A SURVEY Parcel Information Parcel Number: H9080A0025 Township: Shady Grove NCPIN Number: 5789639038 Municipality: Account Number: 8305531 Census Tract: 37059-804 Listed Owner 1: AMH 2015-2 BORROWER LLC Voting Precinct: EAST SHADY GROVE Mailing Address 1: 30601 AGOURA ROAD SUITE 200 Planning Jurisdiction: Davie County City: AGOURA HILLS Zoning Class: DAVIE COUNTY R -A State: CA Zoning Overlay: Zip Code: 91301 Voluntary Ag. District: No Legal Description: LOT 25 FALLINGCREEK FARM PHASE I Fire Response District: ADVANCE Assessed Acreage: 0.92 Elementary School Zone: SHADY GROVE Deed Date: 9/2015 Middle School Zone: WILLIAM ELLIS Deed Book / Page: 010010012 Soil Types: PaD,PcC2 Plat Book: 0007 Flood Zone: Plat Page: 096 Watershed Overlay: DAVIE COUNTY Building Value: Land Value: Total Assessed Value: Outbuilding & Extra Freatures Value: Total Market Value: All data Is provided as Is without warranty or guarantee of any Idnd either expressed or implied Including but not limited to the Davie County, Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to �pUpi'C4 NC or arising out of the use or Inability to use the GIS data provided by this website. Penfrrttee'srf' DAVIE COUNTY HEALTH DEPARTMENT T / ' PROPERTY INFOR _ Name: f .I j� rir�or�mental Health Section MATION `!. ,std Box 8�8 '1 Directions to property;% r' f,�. / 1 ' 1' ocksville, NC 27028 Subdivision Name: �. Phone #: 336-751-8760 Section: Lot: OGjy ' AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - - AUTHORIZATION NO: 002596 A RZfime • / CCI fo **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 with Article 1 I of G.S. Chapter 130A. Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems) i ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION -t %4 i` , 4 -' �" ,.r� �t 'T��'_, • )� IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS #BATHS�- # OCCUPANTS —S GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)\ 1 NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PU P TANK GAL. TRENCH WIDTH-- ROCK DEPTH J?4/ � LINEAR FL„� OTHER'- REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT L Vj=J' U Y C ' i II FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1 OPERATION PERMIT SY INSTALLED BY: AUTHORIZATION N . � OPERATION PERMIT BY: DATE: **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 02J02 (Revised) -A ;?--7,q-0 ':..�...ly— DAVIE COUNTY HEALTH DEPARTMENT p "- f Q ; y. Aronmental Health �ection PROPERTY INFOR ATION ` �.LPiA Box 848 erty;! �` ' " ' ^ Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: Lot: 1 AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION 11 �- AUTHORIZATION NO: ,:.. 00250-6 A RoMrne: I11 / 1 w C2;w 6 *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'with Article I 1 of 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. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE - #BEDROOMS _ #BATHS_ .I�_. # OCCUPANTS GARBAGE DISPOSAL: Yes o� No ; s :34 .,y, y,•yis COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEAiS INDUSTRIAL WASTE: Yes or No r LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK ` GAL. TRENCH WIDTH ROCK DEPTH r 7 �LINEAR FL. -9 c' OTHER f`(� /�Y�!p V♦� !� �' ,'rs�.f �y REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT L) d: r FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALCBETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. IV OPERATION PERMIT SY jjI�NSTALLED BY: Y � AUTHORIZATION NG. 27ZOPERATION PERMIT BY: DATE: VF i "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSITALLED 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 02102 (Revised) • ermittee's + DAVIE COUNTY HEALTH DEPARTMENT �'`�/�r _ Name: Environmental Health Section ROPERTY INFORMATION t r`Z1 P.O. Box 848; Directions to property: � AU ll 4.OR Mocksville, NC 27Q28 Subdivision Name: �j Phone #: 336-751-8760 Section: f Lot: r AUTHORIZATION FOR WASTEWATER!f SYSTEM CONSTRUCTION Tax Office PIN:# .- ( A Road Name: To <<i n �.�et� AUTHORIZATION NO: 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 with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOM # BATHS # OCCUPANTSGARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE/J # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: YesorNo LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)1, NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANKj�GAL. ,TRENCH WIDTH ROCK DEPTH LINEAR FTclJ OTHER DCl1T TTDCr%CTTC•Af%r%TCT!` ATTIIATC//YIATTTTTr%XTC. "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 Au SYSTEM INSTALLED BY: �b AUTHORIZATION N01��ad OPERATION PERMIT BY: ALDATE: **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 02102 (Revised) AA / 0oo—j 7Q v DAVIE COUNTY HEALTH DEPARTMENT 5-:�rs -0 Environmental Health Section / P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990002780 Tax PIN/EH #: 5789-63-9038BH Billed To: Blake Hope Subdivision Info: Falling Creek Lot # 25 Reference Name: Location/Address: 140 Rolling Meadow Road -27006 Proposed Facility: Residence Property Size: see map ATC Number: 3438 **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. 3 ptr J Ft t l/2to Residential Specification: Building Type #People —S #Bedrooms _ #Baths - 3: Dishwasher: P111, Garbage Disposal: Pr Washing Machine: 0' 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 0"' Repair ❑ System Specifications: Tank Size 1,0A0 GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench WidthJA��L Rock Depth 1-9 "Linear Ft: ' 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.**** x3toXIZ" Environmental H11th Specialist's Signature: Di Date: (cl `o L-9,3 DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002780 Tax PIN/EH #: 5789-63-9038BH Billed To: Blake Hope Subdivision Info: Falling Creek Lot # 25 Reference Name: Location/Address: 140 Rolling Meadow Road -27006 Proposed Facility: Residence Property Size: see map ATC Number: 3438 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: 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. V � �• y ,to a 2� 1� 2 Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002706 Tax PIN/EH #: 578X9-63-9038 JH Billed To: Jeff Hayes Subdivision Info: Falling Creek Lot # 25 Refe;ence Name: Location/Address: 140 Rolling Meadow Road -27006 Proposed Facility: Residence Property Size: see map ATC Number: 3438 **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 Specific tion: Building Type #People #Bedrooms L #Baths Dishwasher. Garbage Disposal Washing Machine: �asement w/Plumbin Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industriall Waste: 13Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: New 0 Repair ❑ System Specifications: Tank SizeA0& GAL. Pump Tank GAL. Trench Widt1���/Rock Depth v4 Linear Ft -d Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) 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.**** L Environmental Health Specialist's Signature: Date: 0 (/ DCHD 05/99 (Revised) � �02, v DAVIE COUNTY HEALTH DEPARTMENT " Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002706 Billed To: Jeff Hayes Reference Name: nupubuu rcluilily. IRCSIUCI KA; ATC Number: 3438 Tax PIN/EH #: 57879-63-9038 JH Subdivision Info: Falling Creek Lot # 25 Location/Address: 140 Rolling Meadow Road -27006 rf Uptn Ly JILC. SCC 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 RUCTION IS VALID FOR A PERIOD O1F/FIVEc�YEARS. Environmental Health Specialist's Signature: Date: 7 GO 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) Date: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 S ; 0,3 SG �.G♦ O IMPROVEMENT/OPERATION PERMIT L'" Account #: 990002706 Tax PIN/EH #: 57819-63-9038 JH Billed To: Jeff Hayes Subdivision Info: Falling Creek Lot # 25 Reference Name: Location/Address: 140 Rolling Meadow Road -27006 Proposed Facility: Residence Property Size: see map ATC Number: 3438 **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. ResidentialSpecific tion: Building Type j #People � #Bedrooms _ #Baths Dishwasher Garbage Disposal, Washing Machine: Basement w/Plumbin Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industriall Waste: 130 Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Sizer GAL. Pump Tank GAL. Trench Widtkf4KRock Depth /Linear Ft Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT.-' APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a reprei' ntative 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 1x30 p.m. on the day of installation. Telephone # is (336)751-8760.**** 4i Environmental Health Specialist's Signature: Date: 0 (/ DCHD 05/99 (Revised) r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002706 Billed To: Jeff Hayes Reference Name: roposea Facility: Residence ATC Number: 3438 Tax PIN/EH #: 57879-63-9038 JH Subdivision Info: Falling Creek Lot # 25 Location/Address: 140 Rolling Meadow Road -27006 size: see 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 CO S RUCTION IS VALID FOR A PERIOD OAF/FIVE c�YEARS. ? Environmental Health Specialist's Signature: Date: 7 " q �J 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) Date: --------------- APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT Davie County Health Department Environmental Health Section APO 2 1 2003 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 N EAMRONMENiAI (336) 751-8760 NMUDAVIE L NTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1: Name to be Billed Contact Person S Mailing Address ��i �,/Lf ��� �/ Home Phone City/State/ZIP fTG�1��/lGri �� ��%(�� iO Business Phone��� Did 2. Name on Permit/ATC iif�—'Different than Above Mailing Address City/State/Zip 3. Application For: YvSite Evaluation ❑ Improvement Permit/ATC ❑ Both IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: . ACounty/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes /)ONO If yes, what type? "IMPORTANT' CLIENTS AIUSTCO,UPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESUBMITTED by the client with THIS APPLICATION. (''/ X 306,% Property Dimensions• tr lv ` 240, ?,1 -2,RITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: #S'% 92 i J f Dag �b O �� S Property Address: Road NameJq6ZLLgNe �! &Pow A%. CPO/ - 7/-V Q l�f City/Zip 1� �1 vie Lice 1' C t7A� G'/22G1-S 7AIG-0 /e If in a Subdivision provide information, as follows: Namesio ulo�d�rGe�-c3E�� Y,'°h�Vti-S lZ /I-/- Section: Section: Block: Lot: �'� Date Property Flagged:til--if 16-4 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 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 h e? 1/1 t ,jAel to conduct all testing procedures as necessary to determine the site suitability. DATE / �� SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (I elude all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. Z-7 0 `P Invoice No. 4. System to Service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People _ # Bedrooms # Bathrooms"±._ Dishwasher l j arbage Disposal Washing Machine ,WBasement/Plumbing / ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: . ACounty/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes /)ONO If yes, what type? "IMPORTANT' CLIENTS AIUSTCO,UPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESUBMITTED by the client with THIS APPLICATION. (''/ X 306,% Property Dimensions• tr lv ` 240, ?,1 -2,RITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: #S'% 92 i J f Dag �b O �� S Property Address: Road NameJq6ZLLgNe �! &Pow A%. CPO/ - 7/-V Q l�f City/Zip 1� �1 vie Lice 1' C t7A� G'/22G1-S 7AIG-0 /e If in a Subdivision provide information, as follows: Namesio ulo�d�rGe�-c3E�� Y,'°h�Vti-S lZ /I-/- Section: Section: Block: Lot: �'� Date Property Flagged:til--if 16-4 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 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 h e? 1/1 t ,jAel to conduct all testing procedures as necessary to determine the site suitability. DATE / �� SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (I elude all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. Z-7 0 `P Invoice No. , ..L.... .Zy... S /� st X47 Ctii ZA -/O vm C901?TMY •, A31� i r i 4 Cr 43C.'' 281.2 148.71 i ■& A..1 • �, \ / AN / \ Y Aerlw Parcel 41, Tax Map H-9 \ r's• Horola E. Crews \ $ 0.8.162.Pg.800 l��`�'' Ile Parcel 40.01. \\` •a�:y OOG� \ Tax Mcp H-9 �V�` y; 3 WBliam S. Crews CJ —o g 0.8.163.Pq.777 1 1.028 Ac.t tri \ re..lr, .r ,fr..s r .,1..�. c•! +.) s..... ow.e atel.. 1 .Af.�rtltf 1..t M D.r.:ti�b 11./M 7M�� r rlwbt A. reM. w11.1/ f�y7.. ►� Y• Af.l w flrrll �N r/11�� \ ..rr+f y w� r w. w •�c t.er..r .. w..... r s.r .wr. ,.Ifh .,. a..l... ri..�l► o000n ...w� .,...+,... �w iw Yt....r tl.l. carne., Y,. �.11.11w r w w111w of wra r.11.s lwl. sacs OCT ...w... r.•+ • e+—d caw''/µ}'ms° \ \ pr coop :.rm ole.r F,ALIMc K JrlA" OrXL%1D91'lLOMJR 0< 0.774 Ac.t ryj C . 237.68' z2— j 1 Parcel 40, Tax Mao H-9 \ John Alby S05 28'36'W -- 27 0.3.76,Pg.371 \ \ \ 4 ; �A �\\ \ \ �'\ 501 `17_35*W d �'�lel tri \ re..lr, .r ,fr..s r .,1..�. c•! +.) s..... ow.e atel.. 1 .Af.�rtltf 1..t M D.r.:ti�b 11./M 7M�� r rlwbt A. reM. w11.1/ f�y7.. ►� Y• Af.l w flrrll �N r/11�� \ ..rr+f y w� r w. w •�c t.er..r .. w..... r s.r .wr. ,.Ifh .,. a..l... ri..�l► o000n ...w� .,...+,... �w iw Yt....r tl.l. carne., Y,. �.11.11w r w w111w of wra r.11.s lwl. sacs OCT ...w... r.•+ • e+—d caw''/µ}'ms° \ \ pr coop :.rm ole.r F,ALIMc K JrlA" OrXL%1D91'lLOMJR x APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT n n 17Mm {.'. Davie County Health Department n l _5 LI 1J Environmental Health Section u P O. Box 848 AUG - 6 1997 • Mocksville, NC 27028 (704)634-8760 L:; ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE ALL THE REQUIRED INFORMATION IS PROVIDED. 1. 1, ime to be Billed W e-s� // /c uJ 4be✓e4x oAX Z. Contact Person 61,)4 Mailing Address o� S Sr�c tV StP a Ya rd kl Home Phone % %�i' g 4/a City/State/Zip �� ws �N d -5P4lu, A( e , Q 710 3 Business Phone 9-991-116-7 2. Name on Permit/ATC if Different than Above 5�4 m -g- Mailing Address City/State/Zip 3. Application For: 0' Site Evaluation ❑ Improvement Permit & ATC ❑ Both 4. System to Serve: 5. If Residence: ` ❑ Dishwasher 6. If Business/Other: # Commodes ❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other # People # Bedrooms # Bathrooms ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing Specify type # People # Sinks # Showers # Urinals # Water Coolers ' If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Tpe of water supply: ❑ County/City ❑ Well U Community 8. 1 a you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ 'No Ii yes, what type? _ PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUSTBE SUBMITTED WITH THIS APPLICATION. Property Dimensions: qg, w 74 At ke-s 1 WRITE DIRECTIONS (from Mocksville) TO PROPERTY Tax Office PIN: # �57 g!j 63 - - % 03 Property Address: Road Name 1tow 961. City/Zip AJ,1;4 e!� If480ubd�st provide informM777f A M as follows: �a�s 1 QV L Name: �i�to Section: Lot #: S 1 l* 1 G nCo f - 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 i falsif`�d or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to j the A i horized Representative of the Davie County Health Department to enter upon above described property located in Davie County i and,o. vned by < to conduct all testing pr:'zedures �H as necessary to determine the site suitability. `- DATE -9-6-97 SIGNATURE Revised DCHD (06-96) c� a R r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME PROPOSED FACILITY SUBDIVISION G Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit ZI-11— DATE EVALUATED PROPERTY SIZE ROAD NAME Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position ' Slope % iF3 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 2Z _ i Texture groupG' Consistence i 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: /-� '-)✓ Aqa[ LONG-TERM ACCEPTANCE RATE: REMARKS: _✓/ ",4,19 DCHD (O1-90) EVALUATION BY: vw / OTHER(S) PRESENT: I - a '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