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285 Main Church Road Lot 3 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005221 Tax PIN/EH M 5749-09-3287 Billed To: Jonathan Walsh Subdivision Info: Potters Field Estates Lot#3 Reference Name: Location/Address: 285 Main Church Road-27028 Proposed Facility: Residence Property Size: 1.063 ATC Number: 4942 Site Type: ❑New ❑Repair ❑Expansion **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 3 #Bathrooms fit#People'�I— Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size G�3 Type of Water Supply: 06ounty/City ❑Well ❑Community Well U �,( System Specifications: Design Wastewater Flow(GPD)3&O Tank Size I! Q_GAL.Pump Tank /4GAL. Trench Width 30+ Max.Trench Depth�Le rRock Depth1� Linear Ft. 3�t / Site Modifications/Conditions/Other:_ As &Wed in 15ANC,IC ISA-190%5 fteepted SyztwnQ ;:nw al��-t a�� 0 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. ''Y 5-/ 104b 4r, o' Of- I X11 10'M 1 h_. y41,3 Environmental Health Specialist Date: DCHD 11/06(Revised) Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990005221 Tax PIN/EH#: 5749-09-3287 Billed To: Jonathan Walsh Subdivision Info: Potters Field Estates Lot#3 Address: 205 Tittle Trail Location/Address: 285 Main Church Road-27028 City: Mocksville Property Size: 1.063 Reference Name: Proposed Facility: Residence **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. Pemut Type: 2<ew ❑Repair ❑Expansion Permit Valid for: ears ❑No Expiration Residential Specifications: #Bedrooms—3— Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):360 Type of Water Supply: ❑ ounty/City ❑Well ❑Community Well -)�Site Modifications/Permit Conditions: As stated in 15A NUZ 18A.196 5�saoopted—S to �I System Type LTAR Initial Repair j,{ go 7 Site Plan K5 ol o r � t ` d 5-0 Lb �S Environmental Health Specialist ate o� —�!/ _D i.p.l 1-06 APPLICATION FOR SITE EVALUATION/IMPROVEME QAC ' �r�.�.Gir1 Davie County Environmental Health wo 5 J b� P.O.Box.848/210 Hospital Street FEB 10 2009 7Mocksville,NC 27028 -J (336)751-8760/Fax(336)751-8786 ENVi OA INJEUTALH Application For: ❑ Site Evaluation/Improvement Permit ❑Authorization To Construct(ATC) LTH Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Faci i ***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 0 n ae-N W a l S Contact Person Billing Address q-g--D -2 -r;+ -1 e— +✓rL 1 Home Phone 336 75/- 11299 City/State/ZIP #1 V C k$f!/C ,V L 2 7 0'Z 8 Business Phone_33 6 2-R 7 - w l 5 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 lat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) �/� Owner's Name Gk e 1 Phone Number Owner's Address 2 8 8 5 r✓IeClirori c5 'Dr S-1 efl AN- City/State/Zip f J bQ&t-nr, F! 3 2 93 Property Address 85 ct:n c . l2 City NO C 0 VC 2-70 Z g Lot Size 1. 063 Tax PIN# 5,7q969-3297 Subdivision Name(if applicable) A Section/Lot# 3 Directions To Site: D W /5S atn C4. 12J. (e /o o , Le as r d 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 E�No Does the site contain jurisdictional wetlands? ❑Yes 5&o Are there any easements or right-of-ways on the site? 2Yes ❑No Is the site subject to approval by another public agency? ❑Yes E�No Will wastewater other than domestic sewage be generated? []Yes VNo IF RESIDENCE FILL OUT THE BOX BELOW #People 2 #Bedrooms 3 #Bathrooms Z Garden Tub/Whirlpool des ❑No Basement: ❑Yes Colo Basement Plumbing: ❑Yes ❑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: P&nventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water B/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 Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or stakin the house/facility location,proposed well location and the location of any other amenities. 4 Site Revisit Charge Prop owner's or owner's legal representative signature Date(s): Client Notification Date: Date / EHS: Sign given ❑Yes ❑No Account# O z2 Revised 11/06 Invoice# w rA'` 2f in f I ,.Q 303 J J Ir r I ^I 295 J f f f Ij 285 r 2733 f � rl f 2T CL� �J f r 1 f I rr I Ij rr I f � r I 1 I 0 o44R r I QoMAPS -Davie Cbunty NC Public Access Page 1 of 1 Davie County, NC - GIS/Mapping System 0 rpm'7p Click Here To Start Over Quick Search:(County ID or Owner Ni Active Layer. 0 Use(*lap TIPS 01U14-1-- PARCELS(Map Tips Available) Addre ( v Ln I co CO q I ( I r?� \�,� . ( 4 �r ,' k('� 303 I 2954f v r SIN ( 285A (i 2730 � I 267j, 230 (l 165 �f a r 2371 jQs r I ! I 166 0 59ft �! http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?maimnapservice=gomaps&CFID=412... 2/10/2009 y Davie County Environmental Health P.O:Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 ;l WELL PERMIT Account #: 990005221 Tax PIN/EH#: 5749-09-3287-Well Billed To: Jonathan Walsh Subdivision Info: Reference Name: Location/Address: Main Church Road-27028 Proposed Facility: Resident-Well Property Size: 106x451 ATC Number: 0025 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 be n a material change in any fact/circumstances upon which this permit was issued. Permi Type: New it ❑ AbandonmentE] `'1 C QUI Proposed Well Locatiio r-DiagR A. f Certificate of Completion Diagram 1 -C� I F•o#% IIZN 0 ! LkiQ I , A r•c a �.e u _ 1 Comments:AL�� !/1'�t'� / 4 r� Driller: Certification#: Grout Inspected: ,Lk_3y U'q Well Head Inspected: 'Z�� .9 a q GPS Coordin . /es:' 3� 6 sG. /Ff 3 3 ( -7 EHS: /i% Date: 2-3 Q( EHS: Date: /U''�� 8 W.P.7-08 W l a S4rnpX---T#VJi#t- 7010 IP . ATION FOR PRIVATE WELL PERMIT avie County Environmental Health �E� 2 2009 P.O. Boa 848/210 Hospital Street Mocksville,NC 27028 ENNIRONtAEN Nt"fam (336)751-8760/Fax(336)751-8786 DAVIE COUI�ZY ' ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name to be Billed —,TO—rX a gCtr--. Wc". 1 :5), Contact Person Billing Address 2D 5 T'i 4-+IP 7'r(&'� ( Home Phone .336 &Z-q/&S City/State/ZIP frl0C*sU, 1 IP 1 10 C_ Business Phone Name on Permit if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accom any this application. Included: ❑ Site Plan ❑Plat(to scale 2 (�5 Owner's Name ,oy.o� ��-- LJ l S Phone Number t V7" Owner's Address 5 `Ti 4 4 1-e r rL i I City/State/Zip m rCk S c/11 r .,vr- y7 0 2 Property Address /;Ian C . City /11 v c tS v, 1 Ip Lot Size 106-A- u S 1 Tax PIN# 6- -0 9297 Subdivision Name(if applicable) Section/Lot�# Directions To Site: 1 - 5$- L� o^ M2)— M k r 4- 2 - 1 M,Le o r- If T 7— DEVELOPMENT INFORMATION Permit Type: New Well 1/ Well Repair Well Abandonment Other(specify) M Facility Type: Residential Food Service Church Commercial Other Are There Any Septic Systems Currently On The Site? YES NOy Do You Intend To Install A New Septic System On This Site? YES_"__1 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 comers. The applicant is responsible for making the site accessible. 113y 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 determine the best location for a well. Sign Date Site Revisit Charge Date(s): Client Notification Date: EHS: 7/1/08 . Account# �ZZ/ Invoice# `•� DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account M 990005221 Tax PIN/EH M 5749-09-3287 Billed To: Jonathan Walsh Subdivision Info: Potters Field Estates Lot#3 Reference Name: Location/Address: 285 Main Church Road-27028 Proposed Facility: Residence Property Size: 1.063 ATC Number: 4942 Site Type: ❑New ❑Repair OExpansion **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 1 I 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 `3 #Bathrooms People'�i— Basement❑ Basement plumbing Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size G�t3 Type of Water Supply: 060unty/City ❑Well ❑Community Well U Systeln Specifications: Design Wastewater Flow(GPD) 3(�D Tank Size_j0_GAL.Pump Tank W/,4-GAL. � , Trench Width 3G+ Max.Trench Depth 34P Rock DepthL7 _ Linear Ft. L134, , tf�� Site Modifications/Conditions/Other: !+s stated in 15A NCAC 188.196,9 ^t$d Sj� tems i��y sl , „s, 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. 145/ too on jo I 1 LI to M I IL. 11413 Environmental Health Specialist DCHD 11/06(Revised) DAVIE COUNTY WELL CERTIFICATE OF COMPLETION CHECKLIST Applicant: G yG! .l�•F i File #: Site Address: 4 Subdivision: Lot: Permit Type: New Well ✓ Well Repair Well Abandonment Other Facility Type: Residential Food Service Church Commercial Other nitial 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? N •1 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: �- �6y0f What is,the Well Diameter?6_in. . GPS Coordinates:N33 ��� 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? —A&A— Is There a Hose Bibb? i— What is the Casing Height?J Is There any Grout Settlement? What is the Static Water Level? ft. What is the Yield? GPM Is the Well Contractor ID Riate Complete.?�_ Is the Pump Installer ID Plat omplle/ete? Contractor Name: 5-e l Pump Installer Name: trSS cG� 2 3 Contractor Certification #: Date Installed: Depth of Well:. Depth of Pump Intake: O Casing Depth and Inside Diameter: �� Pump Horsepower Rating: 3 Screened Intervals: Opening for Piping &Wiring >_12": Packing Intervals (Sand Packed Wells): Yield in GPM or GPM/ft.-dd: �1 Static Water Level and Date Measured: �'- Date Well Completed: �O�ot0 Well Head Inspection Date: l0^,),6-0 EHS ID: Li U Construction Completed Date: `1� ' -0 Contractor Reports Received Date: Sample Date: 0-<:� Results Mailed Date: Certificate of Completion D CQ O v Authorized Agent: '�i`� Td� o .RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR CERTIFICATION#,.1,A.31 R 1.WELL CONTRACTOR: f. DISINFECTION:Type a 7-14 Amount C + Wee Ru,--.Set I g. WATER ZONES(depth): Wdl CorAractor(Individual)Name From &b To -54- From To Lt.S S l i W Ell r t lir !� iy C. From To From To Well Contractor Company Name F=rL_TciL From To STREET ADDRESS o7 ' L-t+b e r7f"y �t �_ c�( 6. CASING: Thickness/ From�_To �Ft Depth Diameter Weight Mt e�rial loe-svlll-e It/C. 8� �1 City or Town State Zip Code From Tc Ft L9;Lg} &3-:2 _ 3 to/ F h - From To Ft Area code- Phone number O 3 7. GROUT: Depth Material Method 2.WELL INFORMATION: • From [t___Ton•,Q_Ft SITE WELL ID OR apprcable) Fnm To Ft STATE WELL PERMiT#{d appricabieL From To Ft DWQ or OTHER PERMIT#('d applicable)_ S. SCREEN: Depth Diameter Slot Sae Material WELL USE(Check Applicable Box):. Residential Water Supply(� From To Ft (n. . in. From To FL in. in. DATE DRILLED 4� `/--/, 9 From To Ft in. in. TIME COMPLETED AM❑ PM p-- - _ .. :9. SAND/GRAVEL PACK: 3.WELL:LOCATION.- Depth Size Material From CITY: i�lLzld, COUNTY tC�J To Ft From To Ft `From To 1 Ft (Street Name.Numbers.Community.Subdivision.Lot No..Parcel.Ip,Code) TOPOGRAPHIC!LAND SETTING:- 10.DRILLING LOG ❑Slope❑Vapey t ❑Ridge ❑Other From To Formation Description ( pda�br)_ D CS /?mit LATITUDE be in ftr-s- J6�j mn,tcs,=conds or LONGITUDE JdL 33. / a aee;alal format Latitude/longitude source: Y6PS ❑Topographic map: (bcation of we#must be shown on a USGS topo map and attached to this form if not using GPS) 4.WELL OWNER t OWNER'S NAME zlyi nntom, �t�itL�ly STREET ADDRES 9 3.5- City or Town State Zip Code L-)- 'no--At- Area code- Phone number 11: REMARKS: 5.WELL DETAILS: �) a. TOTAL DEPTH-, TS b. DOES WELL REPLACE EXISTING WELL?.YES❑ NO of Casing: I Do HEREBY CERTff 1MTTMS WELL WAS CONSTRUCT N ACCORDAWF WaN C. WATER LEVEL Below Top g• �!J Fr- 15A NCAC 2C.wELL CONSTRUCTION STANDARWAND THATA COPY OF TMS (Use ;'it Above Top of Casing) _._ RECORD HAS BEEN PROVOM TOTHE WELLOWNER d.,TOP OF CASING IS ,� /z FT.Above Land Surface• C i 'Top terminated casing ternated at/or below land surface may require SIG RE OF CERTIFIED WELL CONTRACTOR -DATE a variance in wconiance with I SA NCAC 2C.0118: 0.;YIELD(gpm): METHODOFTEST V'de e- PPJNTE15 NAME OF PERSON CONSTRUCTING THE WELL -Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt.; Form GW4a 1617 Mail Service Center-Raleigh,NC 276994617 Phone No.(919)733-7015 ext 568. Rev.7/05 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990005221 Tax PIN/EH#: 5749-09-3287 Billed To: Jonathan Walsh Subdivision Info: Potters Field Estates Lot#3 Reference Name: Location/Address: 285 Main Church Road-27028 Proposed Facility: Residence Property Size: 1.063 ATC Number: 4942 **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 i the system wild�tior} risfactorily for any given period.of time. 'P y pa l�{P (V/_ (l�J ' ✓ I-3 – 6),? System Type: S.T.Manufacturer Tank Date / Tank Sizel,,22O� Pump Tank Size —Y— System Installed By: 1i z E.H.Specialist: f� 2o0YMS 4 n � i DCHD 11/06(Revised)