230 E Maple AveWell Construction Permit
Davie County Health Department
is t 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Property Owner: Karl and Joanne Osborne
Address: 230 E Maple Ave
City: Mocksville
State/Zip: NC 27028
Phone #: (336) 751-3398
r For Office Use Only
*CDP File Number 138082
PIN Number: J4 -040 -EO -001
Tax Lot #: Tax Block #
Evaluated For: WELL
PERMIT VALID UNTIL: 5/19/2019
Applicant: Karl and Joanne Osborne
7
Address: 230 E Maple Ave
City: Mocksville
State/Zip: NC 27028
Phone #: (336) 751-3398
Property Location & Site Information
Address/Road #: Subdivision:
230 E Maple Ave.
Mocksville NC 27028
Site Address: 230 E Maple Ave.
Phase: Lot:
*Proposed use of Well:
Directions If Other:
Directions: Valley Rd, left by Ingersoll-Rand, second
stop light, turn right E Maple on left
Well Contractor Information
Drilling Contractor Driller Registration
w ,dY -eeS
Perm
*Permit Conditions
-Must meet all setbacks to .200 c rules
GI m u.i— —7 — '?— I
Well location, installation, and protection must meet all state and local regulations and must be inspected and approved by an authorized representative of
the Local Health Department, the permit may be revoked at any time for failure to comply with existing regulations. The siting of the well by the Health
Department is to provide protection from the known possible sources of contamination. The well site may not be changed without written permission from
an authorized representative of the Local Health Department. No volume or quality of water is guaranteed by the Health Department.
*Issued By: 2140 - Nations, Robert *Date of Issue; 0 , 5 , / , 1 , 9 , / , a , 0 , 1 , 4
® Hand Drawing O Import Drawing
Authorized State Agen . **Site Plan/Drawing attached.**
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3961
WELL CONSTRUCTION PERMIT
1sSTo Davie County Health Department
� 210 Hospital Street
' P.O. Box 848
' Mocksville NC 27028
Drawing TVDe: Well Permit
CDP File Number: 138082
County File Number: J4 -040 -Eo -001
Date: 0 5/ 19 .2 0 14
O Inch
Scale: O Block J
r-\ nein ct
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WELL CONSTRUCTION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number:
County File Number:
138082
J4 -040 -EO -001
Date: 0.5./ 19 / .1 0 14
Drawing Type: Well Permit
Page 2 of 2
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'b4/ rl/•Lb14 09:`2q 3367531660 DCEH PAGE 01/02
I,Cery
av
Dr,1 APPLICATION FOR PRIrVATE WELL PERMIT
T • Osier Davie County Environmental Health
4 P.O. Box Sd8/110 Hospital Street
�Cb Mncitsville, NC 27025
9a�' (336)753=G7S0 / Fax (336)753.1680 Y:
***hiTPURTifNT"'*
TIF71S APPLICATION CwMVOT D.rs PROCESSM) UNLESS ALL OF T M REQUIRED INFORMAT.)!ON IS PROVII)7
—It - - —
T
Nance _6r� c:-�, ' or��_� Contact Person
Address �'5 c� Eo. �;r 1`ric t � �i Jc'_ n u E~ Homy, Phone 3 31.- `75 r - 3 3 R• J-
City/State/7_.JP M a r u S i i 11, �. _ _r`1 -C �.3 7 0 d Y 13usineu P.h pnc c cpm e.
Name on Pti- nit if Leff real then Above ��_
Mailing Addre.45 __5 cx ne. City/State/Zip '5 C, rn e--
PROPERTY NFORMATION *Date House/Facility Corners .Flagged
NOTE: A tiurvcy plat or site plan must accompanyy this applicAtion. Included: ❑ Site Plan OPlat (to scale)
Owner's Nam ne-Kc-: l . i J"a c=,,, �- 1L�;6 ll� c r n cr Phone Number :�3 3l, - q.5 l- -.3 3'r s'
Owner's Address 3r. F�1 4.+ m�-� LE City/State/Zip&( oc-n s t .tl_<, o
,...
Pl:operty Address ot,rn c_� City S C e -
Lot Sire o� `� CSC res Tax PIN# "7 2_ UG 7 ( �.� No_ 80-60
Subdivision Namc(if: applicable)_ oV LA Sectiort/Lot# n/ A
Directions To Site: kea-i j to _ LrQ nor c-1 M0C ate 4 ,'
Z> n rri 1) tA4__ -
DEVELOPMENT INFORMATION
Permit Tyre: New Well Well.Repair. —" Well Abandonment _Othrr (specify)
Facility Type: Residential Food Service •r-• Church _l Cotx�tnercial — Other.
Are There Any Septic Systems Currently On The Sita? YES VO I
Do You Intend To Tnsl:all ,A NCW Septic System On This Site? YES NO I/
TERMS AND COND1TrONS:
'Phis appliention must be acomponied by a plat or site plan of time property that includes lbe existing and proposed property lines
with dimensions, the specific location o('tbe facility and any existing or ftuuire appurtenances, the location of any existing septic
systom, sewer lines, water I'mcs, arty CxiSting water supplies and any surface waters 'Thc applicant is responsible for identi Eying
and marking the property lines and corncrs. The applicant is responsible for making the -site accessible.
By signing this application, the Applicant signifies that they understand the terror and conditions and that they give permission for
Dmrie. County Environmental Health representatives to pertbrm necessary field evaluations and procedures deemed r,.ecessaay to
dctrrminc the hest location fpr a well.
Sint
713,010.0
site Revisit C'herge
Date(s): _
ClientNotiPcntien Date:
Account 0
Invoice M