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HomeMy WebLinkAboutEHPR-04-2016-23755 (2).TIF s1 A THIS IS NOT A PERMIT Case # EHPR-04-2016-23755 � � CATAWBA COUNTY HEALTH DEPARTMENT 0 ' .13-21$ , 0 `�Dt PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES M .Tt 1842 :M Environmental Health Plan Review - Septic Malfunction o o AUTH CONST- SEPTIC_MALFUNCTION l7 I� � �"r , ge Owner LOUIS RAY SIGMON, 5556 E BANDY CROSS RD, CATAWBA NC 28609-8978 C:828-241-2883 LRSIGMON @EMBARQMAIL.COM NAME TO APPEAR ON PERMIT Louis Ray Sigmon SITE ADDRESS: 5556E BANDYS CROSS RD, CATAWBA NC 28609 PIN # 368902566013 NAME of SUBDIVISION: LOWELL DEAL-SUGAR FARM UNREC Lot# 1 Section/Block PROPERTY SIZE: Square Feet 57,063.60 Acres 1.31 DIRECTIONS: Hwy 16 South, Buffalo Shoals, Left at Traffic Light, Right onto East Bandys Cross Roads, 1 mile on Left. PRIMARY CONTACT: Owner SEWER TYPE: Septic Tank GALLONS PER DAY: 360 WATER SUPPLY: Private Well DESCRIBE WORK: *Revised 5/2/16 -Added full AC. Tank only will not be sufficient. Tank has collapsed* Open hole in the ground* SITE INFORMATION Do any of the following apply to the property for which this application is applied? If the answer to any of the questions below is"YES", then supporting documentation is required: Does this site contain any jurisdictional wetlands? No Does this site contain any existing wastewater systems? Yes Is any of the wastewater going to be generated on the site other than domestic sewage? No Is the site subject to approval by any other public agency? No Are there any easements or right-of-ways on this property? No APPLICATION FOR: Existing Structure STRUCTURE TYPE: PRIMARY RESIDENCE FACILITY TYPE: House OTHER DESCRIPTION: DESCRIPTION OF House, Pool, Bldg EXISTING STRUCTURES ON SITE(IF ANY) DIM EXISTING STRUCTURE: House 60x34, Pool 18x34, Bldg 8x10 NUMBER OF EXISTING BEDROOMS: 3 #OF OCCUPANTS: 2 PROPOSED CONSTRUCTION BASEMENT? Yes BASEMENT FIXTURES? Yes PLUMBING REQUIRED? Desired system types(Improvement Permit or Authorization to Construct): ACCEPTED: ALTERNATIVE: CONVENTIONAL: OTHER: INNOVATIVE: ANY: YES Other described: Improvement Permits issued as a result of this information are valid for 5 years or may be non-expiring under certain specified conditions.An Authorization to Construct issued by this department is valid for(5)five years from the date issued and is not transferable; Improvement Permits and Well Permits are transferrable. Permits may be revoked if the information on this application, site plans or intended use changes for the proposed facility. I have read this application and certify that the information provided herein is true, complete and correct. Authorized county and state officials are granted right of entry to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am solely responsible for the proper identification and labeling of all property lines and corners and making the site acces.i.le so that a co •lete site ev. uation can be performed. Date: 5- ,2.•--9O/4 Signature of Applicant or Agent _(2. . J iy, I Cto:i„• An Environmental Health Specialist will contact you within 5 working days o applicatirdate. If you need further information or assistance please call 828-466-7291 AREA1 NO-chapplicatinn 05/02/2016 16:31 Page 1 of 7 43,A • CATAWBA COUNTY Case# EHPR-04-2016-23755 ,Q l 2 Public Health Department Subdivision LOWELL DEAL-SUGAR FARM < Environmental Health Division PIN 368902566013 +1° PO Box 389, 100-A Southwest Blvd,Newton, NC 28658 /g.2 o NAME ON PERMIT: ( LOUIS RAY SIGMON), 5556 E BANDY CROSS RD, CATAWBA NC 28609-8978 ( Louis Ray Sigmon) Site Address: 5556 E BANDYS CROSS RD, CATAWBA NC 28609 Property Size: Square Feet 57,063.60 Acres 1.31 Directions: Hwy 16 South, Buffalo Shoals, Left at Traffic Light, Right onto East Bandys Cross Roads, 1 mile on Left. iFEFN11�AMEI'l 1ililr`I'I 't i$a<lih{'h��llillRT'911�1�1'NI.I' �i'i„trlDATEIf pnipiEEAMOUNTj , t. �.".11rl. .', t 1�IJ.1. Jii . u Authorization to Construct (Repair) Fee 04/28/2016 $150.00 Authorization to Construct(Repair) Fee 05/02/2016 $150.00 11,1471 i11, ,, ,:TOTAL FEES 1a 'Y ItI��N��I1t111'� � ��l �t� il'�III� �il�lilD!. bl ili�i'��ii�' 4{�1��� $300100m G V .:. zuni WIC@ It indiastaiI811111'I'klfgar.t'-.` �a�nitt l6pyiil�t�< 0.➢L111Ilt�.E�"°"ata'gl.]�Ig91:,.[�uS�l FEES ARE NON-REFUNDABLE ONCE A SITE VISIT IS MADE OR WORK ON A PLAN REVIEW HAS COMMENCED SYSTEM REDESIGN AND/OR RETRIP WILL INCUR AN ADDITIONAL CHARGE (SEE FEE SCHEDULE) E9-ehappl icat ion 05/02/2016 16:31 Page 2 of 7 4' CATAWBA COUNTY ���;p!� IOOA SOUTHWEST' BLVD ��Ie"li �� NEWTON, NORTH CAROLINA 28658 RECEIPT �\Iwa►vs, PHONE: 828.465.8399 1. ky i, Monday, May 2, 2016 /842 sn1 www.catawbacountync.gov PAYOR: Sigmon, Louis Ray PAYMENTS TRANSACTION NUMBER: TRC-665895-02-05-2016 PAYMENT DATE : 05/02/2016 PAYMENT TYPE: Check 3046 INVOICE NUMBER FEE NAME FEE AMOUNT 05-16-327872 Authorization to Construct (Repair) $150.00 Fee TOTAL PAYMENTS : S150.00 EHPR-04-2016-23755 CASE TYPE: Environmental Health Plan Review WORK CLASS: Septic Malfunction SITE ADDRESS: 5556 E BANDYS CROSS RD, CATAWBA NC 28609 Owner LOUIS RAY SIGMON, 5556 E BANDY CROSS RD, CATAWBA NC 28609-8978 C:828-241-2883 LRSIGMON @EMBARQMAIL.COM ** NO PEOPLESOFT ACCOUNT ASSIGNED ** receipt 05/02/2016 16:31 Page 1 or I 1,A THIS IS NOT A PERMIT Case # EHPR-04-2016-23755 CATAWBA COUNTY HEALTH DEPARTMENT D ' 'o \ :141,7.-'- j PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES ti _ / 184ti sM Environmental Health Plan Review - Septic Malfunction �o. oo AUTH CONST - SEPTIC_MALFUNCT/ON 0 I j Owner LOUIS RAY SIGMON, 5556 E BANDY CROSS RD, CATAWBA NC 28609-8978 C:828-241-2883 NAME TO APPEAR ON PERMIT Louis Ray Sigmon SITE ADDRESS: 5556 E BANDYS CROSS RD, CATAWBA NC 28609 PIN # 368902566013 NAME of SUBDIVISION: LOWELL DEAL-SUGAR FARM UNREC Lot# 1 Section/Block PROPERTY SIZE: Square Feet 57,063.60 Acres 1.31 DIRECTIONS: Hwy 16 South, Buffalo Shoals, Left at Traffic Light, Right onto East Bandys Cross Roads, 1 mile on Left. PRIMARY CONTACT: Owner SEWER TYPE: Septic Tank GALLONS PER DAY: 360 WATER SUPPLY: Private Well DESCRIBE WORK: Tank has collapsed* Open hole in the ground' SITE INFORMATION Do any of the following apply to the property for which this application is applied? If the answer to any of the questions below is"YES", then supporting documentation is required: Does this site contain any jurisdictional wetlands? No Does this site contain any existing wastewater systems? Yes Is any of the wastewater going to be generated on the site other than domestic sewage? No Is the site subject to approval by any other public agency? No Are there any easements or right-of-ways on this property? No APPLICATION FOR: Existing Structure STRUCTURE TYPE: PRIMARY RESIDENCE FACILITY TYPE: House OTHER DESCRIPTION: DESCRIPTION OF House, Pool, Bldg EXISTING STRUCTURES ON SITE (IF ANY) DIM EXISTING STRUCTURE: House 60x34, Pool 18x34, Bldg 8x10 NUMBER OF EXISTING BEDROOMS: 3 #OF OCCUPANTS: 2 PROPOSED CONSTRUCTION BASEMENT? Yes BASEMENT FIXTURES? Yes PLUMBING REQUIRED? Desired system types (Improvement Permit or Authorization to Construct): ACCEPTED: ALTERNATIVE: CONVENTIONAL: OTHER: INNOVATIVE: ANY: YES Other described: • Improvement Permits issued as a result of this information are valid for 5 years or may be non-expiring under certain specified conditions.An Authorization to Construct issued by this department is valid for(5)five years from the date issued and is not transferable; Improvement Permits and Well Permits are transferrable. Permits may be revoked if the information on this application, site plans or intended use changes for the proposed facility. I have read this application and certify that the information provided herein is true, complete and correct. Authorized county and state officials are granted right of entry to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am solely responsible for the proper identification and labeling of all property lines and corners and making the site acces ble so that a complete site evaluation can be performed. Date: 9 — ag-at)/4 Signature of Applicant or Agent rq,z...c� - An Environmental Health Specialist will contact you within 5 working day f applic ton date. If you need further information or assistance please call 828-466-7291 AREA1 139-rhappl]cation 04/28/2016 10:03 Page 1 of 7 48• CATAWBA COUNTY Case# EHPR-04-2016-23755 !kit", Public Health Department Subdivision LOWELL DEAL-SUGAR FARM Q /Foy ):::j Environmental Health Division PIN,/ 368902566013 PO Box 389. 100-A Southwest Blvd,Newton. NC 28658 1842 ,u NAME ON PERMIT: (LOUIS RAY SIGMON), 5556 E BANDY CROSS RD, CATAWBA NC 28609-8978 ( Louis Ray Sigmon) Site Address: 5556 E BANDYS CROSS RD, CATAWBA NC 28609 Property Size: Square Feet 57,063.60 Acres 1.31 Directions: Hwy 16 South, Buffalo ilShoals, Left at Traffic Light, Right onto�Eas�t Bandys�Cross Roads, 1 mile on Left. ft. :7B iff1151 17.11t l i Y p,I9 1I 1 11n1 lilg M1iy fEEENAMP tIFEF AMOUNT r: Authorization to Construct (Repair) Fee 04/28/2016 $150.00 p l ' t lPl 111II'1��1111P 9!'yyl1 p 1P11 I' I'NP N Ig 1 l' I lfppu'i 1 �61 �1 t b �i(rOTAi,.F,�ES�IV�ud9h�.tiaal�1�a I�II�uI����Ik1��4111�1�{IH1id�>iil 'it 1�iY1����1��n l 14111 111A$15�OiltI�t tl.fiIIN, Aenl(wIIIlIL41J444 "4•l l r;'„Jt,NlI IILratili7a lilntotl" .J;91➢I...aaaitlzllles.' ..tltlJ)1i1�1 FEES ARE NON—REFUNDABLE ONCE A SITE VISIT IS MADE OR WORK ON A PLAN REVIEW HAS COMMENCED SYSTEM REDESIGN AND/OR RETRIP WILL INCUR AN ADDITIONAL CHARGE (SEE FEE SCHEDULE) E9-eliappl ication 04/2812016 10:03 Page 2 of 7 cTA11TH THIS IS NOT A PERMIT COUNTY JLU1'' CATAWBA COUNTY HEALTH: DEPARTMENT Application for Environmental Services Page 1 Improvement Permit Authorization to Construct n Septic Repair Septic Malfunction Septic Expansion n New Well Permit E Replacement Well ❑ Well Abandonment❑ /� Well Repair ❑ Existing System Inspection (Pre-Approval Required) ❑ Application is for New Construction n Existing Facility Er Property Address 556; EAST 841 n.,) S X f - Subdivision 4(..4a � , • , Lot# Acres Section/Block/Phase Driving Directions to Property /}!vry //e o 8ailak 540.44- tarer.k4Fhc ow To £C l i 'net 4 G e- / NAME TO APPEAR ON PERMIT? Ft><vner I I Applicant n Contractor Applicant Contact Information Name iIouiS p3xpW _ Address h 15b �a5 i `z/�4'5 A' eL Ca/ac✓ba /VC, c,M Phone 6;025— 02.4'/ - o22g Cell Phone eJ, �t�ty/--g$s2j Owner Contact Information Name Address Phone Cell Phone Contractor Contact Information Name Address Phone Cell Phone WHO WILL BE THE PRIMARY CONTACT? Owner n Applicant [ Contractor Description of Existing Structures on Site 4/ /? # of Bedrooms *t 3 Structure Dimensions a �`� #of Occupants Basement 127Yes n No Basement Fixtures ® Yes a No The Applicant shall notify the local health department upon submittal of this application if any of the following apply to the property in question. If the answer to any question is"yes", applicant must attach supporting documentation. ❑ Yes Ii�No Does the site contain any jurisdictional wetlands? G tes ®No Does the site contain any existing wastewater systems? ID Yes C Io Is any wastewater going to be generated on the site other than domestic sewage? ® Yes � o Is the site subject to approval by any other public agency?/ Yes IQ'No Are there any easements or right of ways on this property? Describe Existing water supply in use ✓Individual Well ❑ Community Well E Semi-Public Well County/City/Township Water Line Is a public water supply available? ** IT Yes No If applying for an Improvement Permit or Authorization to Construct, Please Indicate Desired System Type(s): (systems can be ranked in order of your preference) ❑ Accepted ❑ Alternative ❑ Conventional ❑ Innovative ❑ Other VAny cATA 7B A THIS IS NOT A PERMIT COUNtv, CATAWBA COUNTY HEALTH DEPARTMENT --�' Application for Environmental Services Page 2 No 1M1 Cmoll Proposed Facility Type ❑ Primary Residence n New Residence Addition to Residence # of New Bedrooms *1. Project Description Structure Dimensions # of Occupants Basement n Yes ❑ No Basement Fixtures ® Yes D No n Accessory Structure(s) Describe # of New Bedrooms *j' if applicable Structure Dimensions #of Occupants Accessory Dwelling n Yes n No Plumbing ❑ Yes ❑ No Describe Plumbing Needed I I Multi-Family Residence#Units #Bedrooms per Unit*t - Total# Bedrooms *1. Structure Dimensions Li Food Service Specify Type # Seats Floor Space-Entire Food Service Facility (Sq Ft) # Employees per Shift #of Shifts Dining Area(Sq. Ft.) n Business Specific Type of Business Retail Floor Space # of Employees per Shift # of Shifts Other Facility Type Specify If Church # of Seats Kitchen ❑ Yes ❑ No If Daycare Specify Occupancy Application for Well Construction/Abandonment/Repair Proposed Well Type ❑ Individual Well n Semi-Public Well n Community Well Abandonment Type n Drilled n Bored ❑ Dug ❑ Unknown Well Repair Requested ❑ Yes ❑ No Describe Calculated Design Flow, Commercial t Additional information may be required to determine design flow from certain facilities. This value will be determined during consultation with on-site staff. *Any room that will be intended for sleeping at the time of construction or for future consideration should be noted as a bedroom and counted on all applications.The number of bedrooms will be confirmed by rooms identified on house plans as a bedroom at the time of building permit issuance. This may prevent the need for septic system size increase in the future. j' If structure is plumbed but no bedrooms,calculated design flow is required. ** If No,a well permit must be issued with the Authorization to Construct. SYSTEM REDESIGN AND/OR RETRIP WILL INCUR AN ADDITIONAL CHARGE (SEE FEE SCHEDULE) Improvement Permits issued as a result of this information are valid for 5 years or may be non-expiring under certain specified conditions. An Authorization to Construct issued by this department is valid for(5) five years from the date issued and is not transferable;Improvement Permits and Well Permits are transferrable. Permits may be revoked if the information on this application, site plans or intended use changes for the proposed facility. I have read this application and certify that the information provided herein is true,complete and correct Authorized county and state officials are granted right of entry to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am solely responsible for the proper identification and labeling of all property lines and comers and making the site accessible so that a complete site evaluation can be performed. Signature of Owner or Agent -1 gc), - Date 0115—00/A Printed Name of Owner or Agent gay. I i�"r7Pw Catawba County Environmental Health 1 • .\\\ .W ■ CO 0 N G W I Ty 88p ° ,I A• 3 1111111111 . p I til ^y 60 • V l. \ e i i 1 / - i i SS0 cp9`' 12•61 4 .(S' • N9, OPN� \ ' ...- ":›....,...e."*.........--- --- \ • -- lir ,, • 0 Parcel: 368902566013, 5556 E BANDYS CROSS 1 in=60ft RD CATAWBA, 28609 ' This map/report product was prepared from the Catawba County, NC Geospatial Information Services. Catawba County has made substantial efforts to ensure the accuracy of location and labeling information contained on this map or data on this report.Catawba County promotes and recommends the independent verification of any data contained on this map/report product by the user.The County of Catawba, its employees,agents,and personnel,disclaim,and shall not be held liable for any and all damages,loss or liability,whether direct,indirect or consequential which arises or may arise from this map/report product or the use thereof by any person or entity. Copyright 2014 Catawba County NC 04/28/2016 Parcel Report Page 1 of 1 Parcel Report - Catawba County NC Parcel Information: Owner Information: Parcel ID: 368902566013 Owner: SIGMON LOUIS RAY Parcel Address: 5556 E BANDYS CROSS RD Owner2: null City: CATAWBA, 28609 Address: 5556 E BANDYS CROSS RD LRK(REID): 20187 Address2: null Deed Book/Page: 1026/0419 City: CATAWBA Subdivision: LOWELL DEAL-SUGAR FARM State/Zip: NC 28609-8978 UNREC Lots/Block: 1/ null School Information: School District: COUNTY Last Sale: Plat Book/Page: Elementary School: BALLS CREEK Middle School: MILL CREEK Legal: LOT 1 5556 E BANDYS CROSS RD Calculated Acreage: 1.310 High School: BANDYS Tax Map: 019AY 01001 School Map Township: CATAWBA State Road #: 1813 Tax/Value Information: Tax Rates(pdf) Zoning Information: City Tax District: All in County Zoning District: COUNTY County Fire District: BANDYS Zoning1: R-40 Building(s) Value: $95,300 Zoning2: null Land Value: $16,800 Zoning3: null Assessed Total Value: $112,100 Zoning Overlay: WP-O Year Built/Remodeled: 1969/2000 Small Area: SHERRILLS FORD Current Tax Bill Split Zoning Districts: null/null Zoning Agency Phone Numbers Miscellaneous: Firm Panel Date: 2007-09-05 Building Permits for this parcel. Firm Panel #: 3710368800J Building Details 2010 Census Block: 2011 WaterShed: WS-IV Protected Area 2010 Census Tract: 011501 Voter Precinct: P5 Agricultural District: Proximity Parcel Report Data Descriptions List all Owners Deed History Report Assessment Report This map/report product was prepared from the Catawba County,NC Geospatial Information Services.Catawba County has made substantial efforts to ensure the accuracy of location and labeling information contained on this map or data on this report.Catawba County promotes and recommends the independent verification of any data contained on this map/report product by the user.The County of Catawba,its employees,agents,and personnel,disclaim,and shall not be held liable for any and all damages,loss or liability,whether direct,indirect or consequential which arises or may arise from this map/report product or the use thereof by any person or entity. ©2016, Catawba County Government, North Carolina. All ri hts reserved. )(Cnnejih. 5� S\ *�,h o 10 ec On t\ Pra 4--- http://gis.catawbacountync.gov/nomap/parcel_report.php?key=368902566013&typ=P 4/28/2016 CATAWBA COUNTY;HEALTH DEPARTMENT poCie Telephone: (828)465-8270 TDD: (828)465-8200 WLS #&t22/- O/;l$2 [P AC , Rpr.,Prmt. Opr. Prmt. Sys. Type Well Prmt. Replacement Well X. Well Rpr. Prmt. Owner/Agent W9 is 2..- S .i& ../ Phone Address Sys er /ce rivs lid Subdivision Ci--'-'-'424- +-T-�f`Section/Bloc ase Loth Lot Size /,3 / Direc ions: /4 5 0 / .r. � '"v 2C'/ R S ''A'vdrS Property Address S• -2 Facility: House piN Mobile Home Business Multi-family . Other: Pin Number 36gj -d? - S6 - .0/3 Other . Zoning Approval N N Bedrooms N Seats N Employees . Application Rate GPD Flow Hot Tub or Spa yes/no Special Fixtures Basement yes/no . 100% Repair Area yes/no Basement Plumbing yes/no Water Supply: Private Well Public Semi-Public **4**********4***************44*4444*444**4*********4*4444**#********4*4******4*4**4*****44***4444444*44*#*#4*44*4*4*4*4**4 Type of System: Trench Bed Pump Pump/Panel Panel LPP Other Septic Tank Size Pump Tank Size Nitrification Field: Total Square Feet Depth of Stone Bed Size Trench Width Total Length of All Trenches Number of Trenches Trench Length / / / / / Feet on Center Maximum Trench Depth Distance of Nearest Well *D0 NOT INSTALL SEPTIC WHEN WET* *WELL RECORD REQUIRED AT COMPLETION* *******4*******4*4*******************4***************4*4*44*4********4*4*****4*4***4*4*4*4*4***********4******************* Topo % Slope J Texture Pep L--e `/ /au s-ep SYs Structure a5 f /b-.c Clay Min. Soil Wetness 'Le f 14-----f---r--/-7 6-1 • Soil Depth " Restric. Hoz. at " Available space PS Overall Class S PS U Comments: _ . . . ..- . - -- - - . -_ ...... .............---.........---------#......." t IQ( •d. e xrds Filter Required Riser required when tank is more than 6 inches deep. **NO GUARANTEE OR WARRANTY IS IMPLIED OR GIVEN AS TO THE PERFORMANCE OR LENGTH OF TIME THIS SYSTEM WILL FUNCTION** ************4****4 4*4*4*4*4*4*4****4****4*********4*4******4*********4**4***4***4********4*4******************4***+*4444*** *Improvement Permit has no expiration date and is transferable, but may be revoked if site plans or intended use changes for the proposed facility. An Authorization to Construct is valid for(5) five years from date issued and is not transferable. Well Permit valid for 5 years provided site conditions do not change. Well location, installation, and protection must meet state and local regulations, and must be inspected and approved by a representative of the Catawba County Health Department before any portion of the installation is put into use. The siting of the well by the Health Department staff is to provide protection from known possi urces of contamination. No volume of water is guaranteed at any site by the Health Department. �(�'//� yy�� . Permit Date 7-a - z EHS ,{,o-tq.e,C-_6,C .--ii— Owner/Agent '„ ."„ Septic Tank Installed B /..4 _ / d Date H714 EHS ---r ' ' Well Installed By giterts GVF!t. Well Grout Approval Date '7-19-a I Well Head Approval Date Q$-O,-o Date Sample Collected el OM/ .,Date of Results Df j44101 Results ,fur - . _EHS G- -. . Al?. S White-Office Blue-Building Inspection Operation Permit Yellow-Owrieri Agent Green-Building Inspection Authorization to Construct A CATAWBA COUNTY A IOOA SOUTHWEST BLVD wC V NEWTON, NORTH CAROLINA 28658 RECEIPT pane PHONE: 828.465.8399 Ulesvt; C Thursday, April 28, 2016 1842 sn1 www.catawbacountync.gov PAYOR: Sigrnon, Louis Ray PAYMENTS TRANSACTION NUMBER: "CRC-663186-28-04-2016 PAYMENT DATE : 04/28/2016 PAYMENT TYPE: Check 3044 INVOICE NUMBER FEE NAME FEE AMOUNT 04-16-327744 Authorization to Construct (Repair) 8150.00 Fee TOTAL PAYMENTS : $150.00 EHPR-04-2016-23755 CASE TYPE: Environmental Health Plan Review WORK CLASS: Septic Malfunction SITE ADDRESS: 5556 E BANDYS CROSS RD, CATAWBA NC 28609 Owner LOUIS RAY SIGMON, 5556 E BANDY CROSS RD, CATAWBA NC 28609-8978 C:828-241-2883 ** NO PEOPLESOFT ACCOUNT ASSIGNED ** receipt 04/28/2016 10:02 Page 1 of 1