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386 Covington Drive Lot 70Davie County, NC Tax Parcel Rennrt Wednesday, November 30.2016 Parcel Number: NCPIN Number: Account Number: Listed Owner 1: Mailing Address 1: City: State: Zip Code: Legal Description: Assessed Acreage: Deed Date: Deed Book / Page: Plat Book: Plat Page: Building Value: WARNING: THIS IS NUT A SURVEY Parcel Information H806OA0070 Township: Shady Grove 5789055037 Municipality: 82532821 Census Tract: 37059-804 CARBONE ANTHONY Voting Precinct: EAST SHADY GROVE 386 COVINGTON DRIVE Planning Jurisdiction: Davie County ADVANCE Zoning Class: DAVIE COUNTY R -A NC Zoning Overlay: 27006-0000 Voluntary Ag. District: No LOT 70 COVINGTON CREEK PH III LIFE ESTATE Fire Response District: ADVANCE 1.16 Elementary School Zone: SHADY GROVE Land Value: Total Assessed Value: 10/2013 Middle School Zone: WILLIAM ELLIS 009390987 Soil Types: WeC,PcB2 0008 Flood Zone: 156 Watershed Overlay: DAVIE COUNTY Outbuilding & Extra Freatures Value: Total Market Value: 91'ma�AAll data Is provided as is wMiout warrardy or guarantee of any kind either expressed or Implied Including but not limited to the Davie County, Implied warranties of merchantability or fitness for a particular use. Ali users of Dade Courdy s GIS website shall hold harmless the ?1 C County of Dade, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to 1� or arising out of the use or inability to use the GIS data prodded by this website. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 D ` (336)751-8760 Account #: 989900093 Tax PIN/EH #: 5789-05-5037.A Billed To: Shelton Construction Services Subdivision Info: Covington Creek Lot # 70 Reference Name: Location/Address: 386 Covington Creek Drive -27006 Proposed Facility: Residence Property Size: 1.25 ac ATC Number: 4539 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE * This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section r to issuance of any building permit(s). This Form/Authorization Number should be presented to the avis,ions Office when applying for building permit(s) (in compliance with Article 11 of GI Was CdP Systems, Section .1900 Sewage en nd " osal Systems). THIS ORIZA STEWATER CONSTRU O LI OR A P RIO:7/4U YEARS. Envir ental Health Specialist's Si \� Date: 7 f ETION � **NOTE e issuance of this Certificate o s t described on Improvement/Operation Permit has been installed in complianc 'th Articl 30 , Section .1900 "Sewage Treatment and 3r Disposal Systems," but shall in NO hat a system will function satisfactorily for any given period of time. g !S T 44 ot)-:--� may© 70{41, _Wo C�,j PQCJ, 7 -aq o,J bArx 4 sl -b, h' � `r1aAL-42,, 7, �� 23 1 �•ZS> Septic System Installed By: Environmental Health Specialist's Signature: Date: J D 7 DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section j P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900093 Billed To: Shelton Construction Services Reference Name: Proposed*acility: Residence Tax PIN/EH #: 5789-05-5037.A Subdivision Info: Covington Creek Lot # 70 Location/Address: 386 Covington Creek Drive -27006 Property Size: 1.25 ac ATC Number: 4539 J **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 40'I� #People _ #Bedrooms Is #Baths Dishwasher:. ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbingi-71000, Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift 171#Seats Industrial Waste: Lot Size Type Water Su ply(&V'� / Design Wastewater Flow (GPD) �iW Site: New2j 000, Repair ❑ z�- 2 , System Specifications: Tank Size )� x AL. Pump Tank GAL. Trench Width 3� Rock Depths Linear Ft.r-WC> Other: f UA,, 7jJ1D Required Site Modifications/Conditions: V1 1:- ar 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 f installation. Telephone # is (336)751-87601`**** 1 � \ Environmental Health Specialist's Signature: -'DCHD 05/99 (Revised) ,e,4pvj ��- 10�1— Aez-� Date: APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC vie County Health Department E C U W nvironmental Health Section ` P.O. Box 848/210 Hospital Street r NOV - 7 2006 Mocksville, NC 27028 336)751-8760/ Fax (336)751-8786 MICEIIr7:RUlifAIWImprov ment Permit -2-2ru-1-orization To Construct(ATC) ❑ Both DAVIE COUNTY 'IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed I&- e--, Contact Person Z2� — Billing Address 12 S -7 Jz< A' --v teq w Home Phone there any easements or right-of-ways on the site? City/State/ZIP _/ `/_p ,,, / J , �. L, Z 7 y 'Z Y Business Phone Will wastewater other than domestic sewage be generated? Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION City/State/Zip NOTE: A survey'plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with omplete plat.) Street Address :5 k t. a ,, ; _ -}-. _ _City Tax PIN# Subdivision Name , —_ . , _ ems, - (L Section/Lot# % 0 Lot Size /; -2 s' , Directions To Site: fr-/ �� C' _ _ : ` -/-- e— . _ 1L l _ _ 4- i/_ _ _ _ 4- Date House/Facility Corners Flagged 0 1, If the answer to any of the following questions�`yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes MN -e— Does the site contain jurisdictional wetlands? ❑Yes G- o'Are there any easements or right-of-ways on the site? ❑Yes Is the site subject to approval by another public agency? ❑Yes 3No- Will wastewater other than domestic sewage be generated? ❑Yes L7No IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms Z # Bathrooms2 Garden Tub/Whirlpool ZYes ONO Basement: GN6'- Basement Plumbin es �, } t.. C,,. ,a..(, L,,_ -J � 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: EtCb-n-ventional []Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 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 understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections todetermine compliance with applic able laws and rules on the above described property located in Davie County and owned by C� Property owner's or owner's legal representative signature z.. y Q 6 Date Sign given ❑Yes ❑No Revised 2/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # Invoice it ril APPLICATION FOR SITE EVALUATIONJMPROVEME E T'C� Davie County Health Department { Environmental Health Section AUG 2 2 2006 P.O. Box 848/210 Hospital Street Mocksville NC 27028 ENVIRONMENTAL HEALTH (336)751-8760/ Fax (336)751=8786 DAVE COUNTY Application For: ❑ Site Evaluation/Improvement Permit Authorization To Construct(ATC) ❑ Both ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed .S �� ) _ — C. -, �-... i-:. Contact Person (�fo .- Billing Address 12_T--? U S 14,-y (,-1 L -j Home Phone -7-51- -a 1 e a City/State/ZIP r-1. `iL,"I) ti. L . Z i u Z Y Business Phone -3S- Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat.) Street Address }. ^ �� ; ., . City A:&. . — Tax PIN# S"7 fl5 tSS'a'o3'7 Subdivision Name C _ , {-_ G.-. K- Section/Lot# '70 Lot Size Directions To Site: k t �-,. G _ y ♦ _ _ C < < ►G �, //..., C _ [�--. L Date House/Facility Corners Flagged u S. 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 DN(57 Does the site contain jurisdictional wetlands? ❑Yes ❑llrb'� Are there any easements or right-of-ways on the site? ❑Yes 21, Is the site subject to approval by another public agency? ❑Yes Will wastewater other than domestic sewage be generated? ❑Yes ❑� IF RESIDENCE FILL OUT THE BOX BELOW # People S # Bedrooms S� # Bathrooms Garden Tub/Whirlpool LXes ❑No Basement: es ❑No Basement Plumbing: Gomes ❑No 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: onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: E-tounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? a,,-0 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 permits) 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 understand that I am responsible for all charges incurred from this application. 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 on the above described property located in Davie County and owned by /k=— — , � • �.- , Prope owner's or owner's legal representative signature z�p c� Dat Site Revisit Charge Date(s): Client Notification Date: EHS: Sign given ❑Yes ❑No Account # 90o0.93 Revised 2/06 Invoice # wow p,t,(o-1/—tel C�OM� APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & AT D Davie County Health Department Envinvnmental KeaO SloWan A 19 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-9760 ***ZMP0RTANT*** THIS APPLICATION CANNOT BE BROCESSE'D UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the IMMRMATION BULLETIN for instructions. 1. Name to be Billed 9 G S kwi— Contact Person Q,/'o / Hailing Address Y/1�I!) X Hose Phone city/state/LIP I -yd( Ll eif-e A) L, �.•%y�� Busiaosa Phone Z. Name on Permit/ATC if Different than Above Hailing Address City/Btate/Lip 10, 3. Application For: Oita Evaluation ❑ Improvement Permit/ATC ❑ Both 4. system to service: House ❑ Mobile Rome O Business O Industry ❑ Other a. If Residence: # People # Bedrooms # Bathrooms n Dishwasher 11 Garbage Disposal Cl Bashing Machine U Basement/Plumbing O Basement/Mo Plumbing 6. If Business/Industry/Other: specify type # People # sinks # Commodes # showers # urinals # water Coolers IS FOODSERVICE: # Seats // Estimated (later Usage (gallons per day) 7. Type of water supply: &10unty/City ❑ Well O Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes O No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 4s—.'5 y Tax Office PIN: ii S-771- yL%- 10 Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: C-A1JJ/u"a�'bfi.) ' �ie+Sz �- Ad !off Section: Block: Lot: %D WRITE! DIRECTIONS (from Mocksville) to PROPERTY: f1l fel C a 1111adilb A) 2r=, r 4-!d i1 /'�-k Date Property Flagged: fa ,S a :+ 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 1 am responsible for all charges incurred from thk 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 suit S/�DATE — lJ 0 SIGNATURE 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). Site Revisit Charge Date(s): I Client Notification Date: 1 EHS: Account No. / --), k Y Revised DCHD (07/99) Invoice No. :r • 1 APPLICANT INFORMATION Account #: 990001288 Billed To: Richard Short Reference Name: Proposed Facility: RESIDENCE Water Supply Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5779-942269.70 Subdivision Info: COVINGTON CK III Lot # 70 Location/Address: Covington Creek Drive -27006 Property Size: SEE MAP Date Evaluated: On -Site Well Community - / Auger Boring Pit �/ Public Cut FACTORS 1 3 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH p z Texture group Consistence Structure Mineralogy7+ l' 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: 7 LONG-TERM ACCEPTANCE RA' REMARKS: EVALUATION BY: !' / OTHER(S) LEGEND 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) i ■NEEM■■■MM■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■M■■■■■■■■■■■ ■■■■■E■■■■■■■■■ ■■■■■E■■■■■■■■■ ■■■■■N■■■■■■■■■ ■M■■■■■■E■■■■■■ ■■■■■■■■■■■E■■■ ■■■■■■■■■■■■■■■ ■■■M■■■e■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■e■■■■■■ ■e■■■■■■MENNEMN ■■■■■■■■■■■■■■■ ■■M■■■■■■■■■■■■ ■■M■■■■■■■■■■■■ ■NN■■■■■■■■■■■■ ■■e■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■eeee■■■■■■■ ■M■■S■■■■■■■■■■ ■E■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■E■■■■■■ ■■■■■■■■■■■■■■■ NEEM■■■■■■M■■■■ NOMMEN■■■■■■e■■ ■■■■■■■■■■■■■■■ E■■■■■■■■■■■■■■ u■■e■■■um■■■■ ■■■■■■ SOMME ■■■■■■e■■■■■■■■ ■■EM■■■E■■■■■■■ ■■■■ESE■■■■■■■■ ■■E■■■■■■■M■■■■ ■EEE■■■E■■■■■■■ ■■E■■■■E■■■■■■■ ■■■M■e■■■■■■e■■ ■■■■■E■■M■■E■E■ ■E■■■■■■EN■■■■■ ■■■■■E■■E■■EEE■ ■e■■■■■■e■■E■■■See■■■■■■■■■ilii■■■■■■■■■■■e■■■■■■■■■■■eM■■■■■■■■■■ ■E■■■■■■■■■■■E■ ■■■■■■■■MMMEME■ ■■■■M■■■■■■■■■■ ■NEEM■■■■■■E■■■ ■■■■■■N■M■■N■■■ ■■■■■■■■E■E■E■■ ■E■O■■■■■■■■■■■ ■E■■■■■■■■■■■■■ ■E■■■■■■E■■■■■■ ■ENE■■N■M■■■■■■ ■EEE■■■■E■■■M■■ ■■■■EN■■E■■■M■■ ONE ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ eee■■s■eee■■■■■■■■■■■■■■■■■■See■■■■■■■■■■e■■■■■■■■■ ■■■ecce■■■■■eee■■ ■ecce■■■■■e■■■■■■■■■ee■■■■e■■■■■ ■■■eee■■■e■■■■■■■■■■■E■■■■■■■■■■■■See■■■■■■■■s■■■■■ ■e■■■■■■■■■■■e■■eee■■■■■■■■■■■■■e■■■■■■■eee■■■■■■■■ ■■■■■■e■EEM■■■■■■eie■■■■■■■■■elle■■■■■■■SSSS■■■■■s■ SSSS■iii■■■■■■e■n■�f■■■■■■■■■■■■■i■■■■■■■■■■■■■■■■■■ ■eee■■■■■■■■■■■■�air■■■■■■■■■■■e■■■■e■■■■■■■■Mse■■■ ■■■■■■■■■■■■■MSO■�■■■■■■■■■■■■■■O■■■■■■■■■■■■■■■■■ ■■■■c■■■e■■■■■■c■■c■■■■■■■■■■■■ce■■e■■■■■■ecce■■■■■ ■■■■■■■■■■NN■■■O■■■■■SSS■■■■■■■O■■SO■■■■■■■OOO■■■■■ ■■■■■■■■■■■■■■ee■■e■■eee■■■■■■■■■■■■■■■c■■■■■■■■■e■ ■■■■■■■■■■■■■■■■eie■■iM■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■e■■■■■ecce■■■■�■■■■■c■e■e■■e■■■■■■■■■■e■■■■■e■■ ■ecce■■■■eee■■■ecce■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■E■■■SSSS■■O■■■■■■■■■■■■■■■SS■■■■O■■ ■■■■■■■■■■■■■S■■■■■■SSSS■N■SO■S■■■■■■O■■■■■■■■S■■■■ ■■■■■■■■■■■■■eee■■■■■■■■■■■■■■■■■E■■i■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■SSSS■■■■■■■■e■■■■■■■■■■e■e■■■■■ ■■■■■■■■■■■■■■■■eie■■■■■■e■■i■■■■M■■■■■■■■■■e■E■■■■ 0 MME ONEEME MENNENNEEMEMMENNENMENNEN See■■■■■■■■■eee■See■See■■■■■■■■■■■eee■■■See■■■Ni■■■ ■■■■■See■■■■ecce■■■■■■■■■■■■ece■■■■e■■e■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■S■S■■■■S■■■■eSO■e■■■■■■■die■■■■■■■■■■■■iO■■■■i■■S■ SSSS■■eee■■■■■■■■�iSSSS■■i■■■■■■■■■■■■■■■■■■■■■■■■ ■■lee■■■■■E■■■■■■■■■■■■■■■■■■■■■■■■■Mai■■■■■■■■■■■■ ■■■■■■■eNNNE■ecce■■■■■■■■■■■■■■■■■i■■See■■■■i■■■■■■ ■■■■■■M■EE■■■■■■■�■■■N■■■■■■■■■See■■■■■■■■■■■■■■■■ ■■■■■■■lice■■■■■■ SSSS■■See■■■■■■■■■■■i■■■■■■e■ee■ ■■■■■■e■■■■■■■■■■■e■■■■■■■■■See■■■■■■■e■■■■■■■■■■■■ ■■■■■■■■■■■■■ee■■e■■■■■eee■■■■ecce■■■■■■■■■■■■■■■e■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■e■■c■eN■E■■■■■■■■e■■■■■■■■■■■■■■See■■■■N■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■�Ilie■■■e■lie■■e■i■e■eeeiii■■■■■■■■■ ■■■■■■■■■■■■■eeeei�e■■eee■e■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■M■■■■■■■SSSS■■■■N■■■■■■eE■■■■■■Ei■■■■■■ ■■■■■■■■■■■■■■■■■■�9■SSSS■■e■■■■■■■■■■■■■i■■■■■■■■■■ SSSSecce■■t■■■■■■■■■■■■■■■eE■■■■E■■■■■■■■■■■■■■■■i■ ■■eee■■■■■■■e■■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■ SSSS■■■lee■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ° j R@Isaws APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & AT D Davie County Health Department Environmental Health SaWon A 19 P.O. Box 949/210 Hospital Street Mockaville, NC 27029 (336) 751-8760 ***IMPORTANTk** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Nasse to be Billed 2 G ZS)y�Lf r -i— Contact Parson /C / c A4 ez Hailing Address �i'1 / Boma phone C tut -e- City/atate/Lip ,A�i Vl�tut-e-n) 11 .�. / U��P Business ?hone b l3- 8 `Y J� Z. Name on psrmit/ATC it Different than Above —' Hailing Address 3. Application For: Site Evaluation a. "etas to service: House ❑ Mobile Home S. If Residence: I People City/state/Lip 0 improvement Permit/ATC 0 Both 0 Business ❑ Industry ❑ Other # Bedrooms s Bathrooms n Dishwasher tl Garbage Disposal 0 gashing Machine U Basement/plumbing 0 Basement/No plumbing 6. If Business/industry/Other: Specify type 6 people S Sinks f Commodes ! Showers f Urinals # Water Coolers IF FOODSERVICE: (# Seats 7. Type of water supply: Estimated hater Usage (gallons per day) LCounty/City 9. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community 0 Yes 0 No ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: fess-. S I /-4, Tax Oiflce PIN: # S-771- 91/' <3a- &M r 61 Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: ILL Section: Block: Lot:_ WRITE DIRECTIONS (from Mocicsvilie) to PROPERTY: k 1110-J dt'i r. r � SMRS Date Property Flagged: c6 + _ 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, anderMand that I am responsible for all charges Incurred from this application. 1, 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 conductall testing procedures as necessary to determine the site suit _ DATE SIGNATURE 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). Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. Revised DCHD (07/99) Invoice No.