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274 Baity Rd (2) • DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 OPERATION PERMIT Account #: 990003311 Tax Plltl/1=H#: 5823-30-5596-Storage Billed To: CKJ Building &Design,LLC Subdivision Info: Reference Name: James Blakley Location/Address: 274 Baity Road-27028 . Proposed facility: Storage/Shed/Barn Property Size: , 7:578 Acres ATC Number: 5804 _ **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. t System Type: S.T.Manufacturer,= Tank DateTank Size. t Pump Tank Size System Installed By: arl {�V(C (�(/�i{_ E.H.Specialist: Date: l eYl GPS Coordinate: 5 1 DCHD 11/06(Revised) J L a� t 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 Account #: 990003311 Tax PIN,EH#: 5823-30-5596-Storage Billed To: CKJ Building &Design,LLC Subdivision info: Reference Blame: James Blakley ; Location/Address:,:274 Baity Road-27028 Proposed Facility: Storage/Shed/Barn Prope�ry' ze: 578 gcres. Siteype: ❑New ❑Repair DExpansion AT414bqtborTh0&orization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to 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. l Residential Specifications: #Bedrooms #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type M 49.. #People #Seats Square Footage(or Di ensions of Facility) Lot Size 75—ac, Type of Water Supply: ❑County/City Q Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) _Tank Size GAL.Pump Tank GAL. u Trench Width t Max.Trench Depth'Rock Depth Linear Ft- 2C• Z556 Site Modifications/Conditions/Other: l `n 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. P r LIJ Environmental Health Specialist ALI& 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 1 t� AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990003311 Tax PINIEH#: 5823-30-5596-Storage Billed To: CKJ Building &Design,LLC Subdivision'Info: Reference Blame: James Blakley : Location/Address: 274 Baity Road-27028 Proposed Facility: Storage/Shed/Barn Prop e y ixe: , :-7�578 gcres Siteype: �1New ❑Repair ❑Expansion A14G46TE13orThiMhorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to 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 ensio s of Facility) Lot Size Type of Water Supply: ❑County/City JoWell ❑Community Well System Specifications: Design Wastewater Flow(GPD)qO Tank Size GAL.Pump Tank !G22AL. Trench Width &�P" Max.Trench Depth3a' Rock Depth Linear Ft.3w+ 2s°lo Site Modifications/Conditions/Other: �ef�u�cUh 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. Environmental Health Specialist Date: IbIl DCHD 11/06(Revised) , �---' DAME COUNTY ENVIRONMENTAL HEALTH -YAkt4iJ2d • P.O.Box 848/210 Hospital Street 17gq Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 v AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990003311 Tax PINIEH#: 5823-30-5596-Storage Billed To: CKJ Building &Design,LLC Subdivision Info Reference Name: James Blakley Local€on/Address:. 274 Baity Road-27028 Proposed Facility: Storage/Shed/Barn Property Size: ` 7-.578 Acres Site Type: ❑New ❑Repair ❑Expansion ATC Number: 5804 **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to 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 i� Q� People_L#Seats Square Footage(or D ensio of Facility) Lot Size Type of Water Supply: ❑County/City ❑Well ❑CommunityWell System Specifications: Design Wastewater Flow(GPD) M Tank Size GAL.Pump Tank GAL. Trench Width �.�0 Max.Trench Depth_ Rock Depth Linear Ft. tso gcy-y A, t 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. 14 VQ)R\ 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 IMPROVEMENT PERMIT Account #: 990003311 Tax PIN/EH#: 5823-30-5596-Storage Billed To: -CKJ Building & Design,LLC Subdivision Info: Address: 233 Fallingcreek Drive Location/Address: 274 Baity Road-27028 City: Advance Property Size: 7.578 Acres Reference Name: James Blakley Proposed Facility: Storage/Shed/Barn **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/installation 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: Mew ❑Repair. ❑Expansion Permit Valid for: its Years ❑No Expiration Residential Specifications: #Bedrooms #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Di ensions of Facility) Design Flow(GPD): lwo Type of Water Supply: ❑County/City .Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial Repair d P Site Plan 14 oq Environmental Health Specialis rc� Date i.p.l 1-06 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Boz 848/210 Hospital Street SUN 2 7 X011 Mocksville,NC 27028 (336)753-6780/Fax(336)751-8786 Application%% -- e" valuation/Improvement Permit ❑ Authorization To Construct(ATC) Both Type of Application: 7New 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. APPLICANT INFORMATION I/ _ Name to be Billed C lzWT , Contact Person_ /A,vel�� ,1 ht751,T,– Billing Address e i 01Y Home Phone D– 7 City/State/ZIP Business Phone Name on Permit/ATC if Different than Above 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 monthsit th plan,no expiration,with completeplat.) Owner's Name CG — Phone Number /q& Owner's Address /State/Zip Property Address City Lot size 7, S" K a 6-es Tax PIN# 5-7a 93b5�g1 Subdivision Name(if ap licable) Al Section/Lot# Directions Jo Site: < < G ..yl t-)(,f h < If the er to any of the folio ' g questio is"yes",support' documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes @No Does the site contain jurisdictional wetlands? ❑Yes PNo Are there any easements or right-of-ways on the site? ❑Yes RNo Is the site subject to approval by another public agency? ❑Yes RNr Will wastewater other than domestic sewage be generated? ❑Yes Mo IF RESIDENCE FILL OUT T BELO rd J f cp #People #Bed 6oms #Bathrooms Garden-'rub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Baswent Plumbin : ❑Yes ❑No IF NON-RESIDENCE FILL C UT THE BOX O Type of Facility/Business151A F/!forLANquare Footage of Building St f j�p #People # Sinks_2 1 #Commodes Q #Showers I — #Urinals n- Estimated Water Usage(gallons per day) :,,a (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: v6onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water VNew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes a-14 If yes,what type? Thie is to ePrhfv that the inf hi-nint4rin nrnvirlPri nn thk annliratinn ie Aia and enrrart tntho hPet nfmv irnnwierioP T nrnrierctanrl that 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 Application For: ❑ Site Evaluation/Improvement Permit ❑Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name Contact Person Address Home Phone City/State/ZIP Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners 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 Phone Number Owner's Address City/State/Zip Property Address City Lot Size 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 onthe site? _Yes _No Does the site contain jurisdictional wetlands? _Yes _No Are there any easements or right-of-ways on the site? _Yes No Is the site subject to approval by another public agency? _Yes _No Will wastewater other than domestic sewage be generated? Yes No IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness 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 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 Represen five of a vie County Health Department to conduct necessary inspections to determine compliance with applicable laws an les. nder t that I am responsible for the proper identification and labeling of property lines and corners and locatin ging o t king the house/facility location,proposed well location and the location of any other amenities. Prope o e s wner's lega presentative signature Site Revisit Charge Date(s): �( Client Notification Date: Dat EHS: Sign given ❑Yes DNo Account 4 �3lT Revised 11/06 I oice ..wwT.rr.e..r«.•..r..rr r.r.mer«.»«r awPrr`e�rir..a•er.rw••M4ar4 rwrr sm w NORM CNWLM w:s'.':.w-»',a.:..rr.if:w::'o rra.w.rr.•w.pp twar or amfl-...wuw«r«n ♦.�w_. p e �.�arar.wM..•w..:.':`ir rr..wr' .......rM 1pll _ waw aw w.»..i.a.r»n w wwrwl aPrr.ri w^ l MNiw Web{Mr•Olhw.l r� r r«rnrNrw reie wl Me 23•. .aw 2071 . eo0123e PO a00 O a r.rwar.wwr.rrr.ww.r• �. .r'`iw�i..�a:W 7~iyr• w.rw�. urr.r..n .r.._. 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Baity Road omrE15 I Tap AN.awr Nw+ar IN/2'CP 6rw Rw S.R. 1421 No'0.Natio• , afe'9rw w PA. �R+�'"rw-3" o as 1 i 2TN NSG 27026 �•�• •— a/_eP r� swwww q 427a Pa a SO•Publla R/W % .1 M-Ar 18'+/-Pawma$ C-S %/ 1•V ti Taw/ay an rrw a/r MP ww ^-3/r tl fro T"At.e -....- 'per✓s0,e°p/ 1 ""•.. ..............-----•+ 35ii:� POND,,•. I U d' t I POND `-'"` i Tw W n / 1 ' L' I erm�Ibp e-a ' ira ew LOT 2 •'1 � r'4ra 1 w�13:'Po"'�� + Pr LOT 1 t °1+ � 2.122 Aw. 1 ♦-1r - , .a"•"• w-• =,r.r' ' Q 1. ./- �+ \ ,,• T.W 72.14n/d ,,,,�•1 E-,' - �R M E�M p tTr/e ay°wE \ ImMe e�°i Po tam ••► � o.nr 1'EP Nd \ ��• FA Grnr 1 , 1 ,>✓'` v Survey for. \ { + Tony Alexander Blakley \ Tw W 74 �� & Kay 0. Blakley E/j(l1�/�A±t�0-1 Trt Nr w Im. \ N.srE''/•/ tL-i7'a--l T i POr atol FM-'4233055" '4 Tw 5572 6,Tn MaP w. �w�ra-^�* . ; •r�. \ d. _`/t Baity Road T-wr�r.r N-«•PM /--l' V`LD l-VG Oad Beat,2a OPepe " Ne-/ya rw \` V tOT I A bow 2 A tlmi S e PaVa 9T. ,.�. w.wxr / S.R. 1421 A•••o• / LOT 1 l,22 Aorw+- tr r M w PIIOPOTrY UNE l'Jl1 L1Btt (waiwiw*-ane 6 SR 1+2i 11/l7) 90'PuNb R/w a. nr'r.r'r Ire COIIRX OFOM 01 MU! T[UNE CAL TMLZ 18'+ -Pavement Lor 2 -r-"I wr new earn c7i-e.i eeb r 4 / wHan 61 T�97l04 TU Nap C �awrwvee.. w.-> rM >f L-1 sall-At"w a6sa• Iaga • -rl.r«» w= L-0 E 0179'00'Y Se3.96• OONIFE 86110110 a1sNe10E Rdaranca free)`E^,PW leeY 8 e PeOe E7. . - 7PYW N-wet•eh I L-3 E Oi•3700-e 152.16'2VWLOT 2 737E Herr.+- • �o:3."Yrr"'"r"a las •`+ Lr3 E 3-6 4E21-W T-2 N 2F45'5PN aW.7Y (Lrwrrb M 244.17w w�m.e MI ex.lut/IVwf 1 a•ee.r rrrrr w-Prr rn .i Ir•rw T-3 N SP61'00•N 36732' L-e N 26'S172•w 27waa' fwd Papel A—"9.700 A-+/- a W N 04'60 wz 951EY T3 E 0611 trimolon 31.93' 7-S E 6E•1017'L A.97' R' 0010411 ELw ONE M-arra L-9 N OTOe79'4 2OL9r TN N W3+24-C 446.77 1-.;W Olriewle D.* NeAh C..W. 5-23-2011 L-1011 0410057E 3"Al' Stone�Afld SUN Company.., 100 0 100 200 300 L-11 s 77'eCs7'E Isz i7� �9 P Y L-12 11 0'53'376 204.00' eew..Nr trifle RrWn Flits N11R L-I3 s71V6-ww 21L67 ern.wlEMra ltt L-slet art NL ' GRAHOC SCALE-FEET L-I4 NIs1e2rW 20L6r �� lrr rxr•aw»fi,w 704-.u1 4611 L-IS N 2M V-11 214.90 v+r++a rrN arms , DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION IR�ag ORMATION Account #: 990003311 Tax PIN/EH#: 5823- � Billed To: CK�Building & Design,LLC Subdivision Info: Reference Name: Ja es Blakley .Location/Address: 274 Baity Road-2702 Proposed Facility: Sto age/Shed Property Size: 7.578 Acres Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut ' FACTO S 1 2 3 4 5 6 7 Landscape position Slope% c HORIZON I DEPTH Texture groupG Consistence PIE Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 25 LONG-TERM ACCEPT CE RATETy SITE CLASSIFICATIO EVALUATION BY. LONG-TERM ACCEPTA NCE RATE: ' 7i OTHER(S)PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Should rr 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-Loam sand SL-Sandy loam L-Loam S17 Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSIST FNCE Moist 'VFR-Very.friable -Friable FI-.Firm VFI-Very firm EFI-Extremely first NS -Non sticky SS Slightly sticky S-Sticky VS -Very Sticky NP-'Non plastic SP I 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 Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thic ess and inches from land surface Saprolite-S(suitable),U( nsuitable) Soil wetness-Inches fro 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) T TAR -T nnv-tprm arrent nrP rate-oaUAnu/ftp �d«r%nc Inc m Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 WELL PERMIT Account #: 990003311 Tsx.PIN/EH#: 5823-30-5596-Well Billed To: CKJ Building &Design,LLC ,Subdivision Info-.;' Reference Name: James Blakley r°r :Localion1Address:y 274 Baity Road-27028 Proposed Facility: Building/Well Pf6b0rty Slze`., ! 7.578 Acres ATCEumbafr' 00841 �,• Ac ions o the employees of the Davie County EH Sec for shall iii no way taken as a guarantee that this well will produce water of any particular quantity or quality or for any amount of time. This permit is valid for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there has been a material change in any fact/circumstances upon which this permit was issued. Permit Type: New tK . Repair ❑ Abandonment ❑ Proposed Well Location Diagram Certificate of Completion Diagram nii � Comments: � Q. Driller: Certification Grout Inspected: Well Head Inspected: GPS Coordinates: -EHS: Date: EHS: Date: W.P.7-08 Davie County Environmental Health P.O.Box 848/210 Hospital Street I `� Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 WELL PERMIT Account #: 990003311 Tax PIN/EH#: 5823-30-5596-Well Billed To: CKJ Building &Design,LLC Subdivision Info: Reference Name; James Blakley Location/Address: 274 Baity Road-27028 Proposed Facility: Building/Well Prbperly.Sixu: 7.578 Acres ATC Number: 0084 Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this well will produce water of any particular quantity or quality or for any amount of time. This permit is valid for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there has been a material change in any fact/circumstances upon which this permit was issued. Permit Type: New❑ Repair ❑ Abandonment ❑ Proposed Well Location Dia j Certificate of Completion Diagram 5� I i CoMDrments: iller: Certification#: Grout Inspected: Well Head Inspected: GPS Coordinates: EHS: Date: EHS: Date: W.P.7-08 ATION FOR PRIVATE WELL PERMIT 1Davie County Environmental Health ©111 P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name Ul Contact Person , Address Home Phone City/State IP Business Phone Name on Permit if Different than Above Mailing Address GssJ City/St a/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan m ac mpany this application. Included: VSite Plan ❑Plat(to scale) Owner's Name Phone Number Owner's Address City/State/ ip Property Address 7 City Lot Size Ace-A5 J Tax PIN# Subdivision Name(if a plicable) Section/Lot# # Directions To Site: $ `il� c DEVELOPMENT INFO TION Permit Type: New Well Well Repair Well Abandonment Other(specify) Facility Type: Residential Food Service Church Commercial Other Are There Any Septic Systems Currently On The Site? YES NO Do You Intend To Install A New Septic System On This Site? YES NO TERMS AND CONDITIONS: This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines with dimensions,the specific location of the facility and any existing or future appurtenances,the location of any existing septic system,sewer lines,water lines,any existing water supplies and any surface waters. The applicant is responsible for identifying and marking the property lines and corners. The applicant is responsible for making the site accessible. By signing this application,the applicant signifies that they understand the terms and conditions and that they give permission for Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to deter i a the best I ion for a well. 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L-4 8 26'50'31`E 244.15 T-i 904 272.IY L-6 8 4D•16�1-W 621.36' T-2 N 2V40-57W 594.77 CbwYr+a M aaa N S.R 143{1{/W) \ L-1 N 76r51'J2W 374.•.7' T-t N 20r01'OOrlf 3%S2' - ietd Pl•Iea Arnepa 9.700 Nrrr+ -- 1`.rdf 1-Qdt a..www v 1-4 S 06r1003'E 76.65 / L-7 N 04'00,5'E 790.06• 7-3 5 68-1017'E 3697' Na1L. 1916191' WIMt( 7996 099 M-MM L 1 N 03 mi.9r T-4 N 003474'E 4447. 1•_100 ar6a. Dmb H.%Cere6l.e 6-23-2011 '100 0 100 200 300 L 11 s mar[ 1� Stone Land Surveying Company 1-12 N1Y5.30'L 201.00 ,.0.r Nr 0...%Itr\x1 L-13 871YS4' ' 34"W 2146Y N ,wM\ 2b•41134-1ta ' C SCALE-Far L-I4 N 18-IC277 2OLor 'YM10lu Iti WnPw-•IlT 4Lw N4 . \,� L-IS N27.4ilDn 314.96' am ' ` x.Yw.a,ac •� DAVIE COUNTY WELL CERTIFICATE OF COMPLETION CHECKLIST Applicant: File #;! Site Address: Subdivision: Lot: Permit Type: New Well Well Repair Well Abandonment Other a Facility Type: Residential Food Service Church Commercial "' Other Initial Inspection Were Setbacks Maintained? Yes No What is the Grout Depth? ft. If No, Explain: What is the Grout Thickness? in. What is the Type of Well? Was a Well Screen Installed? What is the Casing Type? Type of Drilling Fluids Used: What is the Casing Depth? ft. Well Grout Inspection Date: What is the Well Diameter? in. . GPS Coordinates: What is the Well Depth? ft. EHS ID: Well Head Inspection Is There an Access Port? Is There a Vent? Is There a 4" Pad? Is There a Hose Bibb? What is the Casing Height? Is There any Grout Settlement? What is the Static Water Level? ft. What is the Yield? GPM Is the Well Contractor ID Plate Complete? Is the Pump Installer ID Plate Complete? Contractor Name: Pump Installer Name: Contractor Certification #: Date Installed: Depth of Well: Depth of Pump Intake: Casing Depth and Inside Diameter: Pump Horsepower Rating: Screened Intervals. Opening for Piping & Wiring >_12": Packing Intervals (Sand Packed Wells): Yield in GPM or GPM/ft.-dd: Static Water Level and Date Measured: Date Well Completed: Well Head Inspection Date: EHS ID: Construction Completed Date: Contractor Reports Received Date: Sample Date: Results Mailed Date: Certificate of Completion Date: Authorized Agent: