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460 McAllister Rd � � .._:�:d' � DAVIE COUNTY ENVIRONMENTAL HE1�.LTH ��.; " ..: , P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 OPERATi01�T PERMiT ' Accc►u�t �: 990005068 . ,. . ,'���c PI�(?EH#: J300000b35 . �iflcd To: Stephen and Mary Hall . �� � Suk�t�ivi�iorl Infc�: � :r�.�� RefereE�ce N�me: ;..:•;�� .. , ;;:;Locai�oniAddr�ss: McAllister Road-27028- °�:. . . . . F'rnposQc9 Fa�;iiity: Residental �; : :-., ;, : Pfo�e►�y�Six�: 25Acres , ,,,, � ,: .' ;,;;;: �T*�*N���'�'The�is uance of this Operation Peimit shall indicate the system described on the ATC has.been installed ' in compliance with Article I 1 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 sadsfactorily for any given period of time. ' � . System Type;,_ � ��L�M"anufacturer�_ Tank Date 7f��1 Tank Size /D� Pump Tank Size i Bedrooms:�_ System Installed By;�!' ��tD Installer# Date:i����— GPS Coordinate: :. � S ' "' ���a� . �h h� � . � � ��..,� N v �� � . "'� . . ' , . � . � .' � . . . � O ` � . . � . ?C�x N . � . ' M � �f �.pr 3� � � ,� ' � J � . . Y- ` ...- �-- � . . . "V V . �� � � - � � . .. � �- ,� : . . . . - . . . _ .. r ' . � I Z�,, � -- ; , Environmental Health Specialist Date: � �S, DCHD 11/06(Revised) ' . � ' �;. . � � . DAVIE COUNTY ENVIRONMENTAL HEALTH I � P.O.Box 848/210 Hospital Street Mocksville,NC 27028 � _ (336)753-6780/Fax#(336)753-1680 �� AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION AGCC�u�lt �: 990005068 . . '�"ax.P1Ni�H#: J300000035 . Billcd`Ca: Stephen and Mary Hall . :: � Suf�divi�iar� fnfo: l.��p' . . . .RefereE�ce �I���e: .. : � > ':�;;�.o�ationiAddre�s: McAilister Road-27028 f�ropc�sQd Fa�ility: Residental ' + ,.,; ��� �=� :.:� �Pfo�er#y•Six�: 25 Acres . . � _ . . . �TC t�umber: 5969 , . . . ` :;, I'�, .. Site Type: f�New ❑Repair �Expansion � **NOTE**This Authorization to Construct(ATC)MLJST 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 Z Basementl�Basement plumbing8l Non-Residential Spec�cations: Facility Type #People #Seats Square Footage(or Dimensions of Facility) . Lot Size�_ Type of Water Supply: �County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) 3Gv Tank Size Db0 GAL.Pump Tank /OCo GAL. Trench Width�_ Max.Trench Depth�(� Rock Depth N//�. Linear Ft.3 28` �5"/e Site Modifications/Conditions/Other: F���+(_� Contact the Davie County Environmental Health Section for final in§pection of this system between J "'�'� � - . 8:30-9:30a.m.on the da of installation. Tele hone# 336 751-8760. ��. , o �+ �.�.-~ � ^`. ` ����� i -�..�` . y �-:.;� � �, . . �.: r � � � ^^, � � � �� .- -. , r � � �\ � � . � - � �. r„ .v, ^ � ar�o� Environmental Health Specialist Date: —_�/�/a�_ _��_ r�run �i m�ruP�,;�P�� , � , . � ��_ _.•_ A . ' . APPLICATIO OR SITE EVALUATIOI�T/IMPROVEMENT PERMIT & ATC ��� Davie County Environmental Health � �"' 2 P.O.Bog 848/210 Hospital Street u� � � 201 lvlocksvi�le,rrc z�o2s A � (33�753-6780/Fag(33�753-1680 Applica� . rte Evaluation/Improvement Pemut L�3"Authorization To Construct(ATC) ❑ Both 'I�pe of Application: ❑New Svstem . �Repair to Existin�System �E�ansion/Modification of Existin�Svstem or Facility ***IMPORTANT"`**THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATIOI�I BUL�ETIN for instructions. APPLTCANT TNFnRMATT(�N Name Sr�Pk{��/ �.A*1� �tf1CL Contact Person_ LANIF, (��_ Address q.is M�A�('tS�f � (�e' J� �eme�hone 336—3lcZ— c�3e4 City/State/ZIP�o�v�)�.� . r(L, Z7p28 Business Phone Email lanehdil@ 2►01.wn� Name on PermitlATC if Different than Above Mailing Address ' City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged /2 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 e�cpiration with complete plat.) Owner's Name"S�p�}En► �,.,A+�� l'�A«.. Phone Number 3�-3leZ—p3�1¢ Owner's Address �►S m�All�s�-r �d City/State/Zip (Ylocks.i�lle .T�l C 2?oZ8 . Property Address � Ii �- City� jcs � � Lot Size ZS Acres Tax PIN# Subdivision Name(if applicable) � � Section/Lot# . Directions To Site: r ' � , �� ' If the answer to any of the following questions is•"Yes",supporting documentahon must be attached: Are there any existing wastewater systems on the 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 generated7 Yes xNo TF RF,STDF,NCF,FTT,T,ni TT THF.RnX RF,T,nW #People Z #Bedrooms 3 #Bathrooms_,� Garden Tub/Whirlpool ❑Yes �No Basement:�Yes ONo Basement Plumbing: J�Yes ONo iF.NAN-RFSTDF,NC;E FTL�:,niJT THE BnX AF.I..OW Type of FacilityBusiness Total Square Footage of Building #People # Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (A h 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 0 Community We�l ,;.: _ . .,.,�y Do you anticipate additions or expansions of the facility this system is intended to serve7 ❑ 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 tfiat 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 under d that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging or s the ouse/ lity 1 atio roposed well locarion and the locarion of any other amenities. Property er's or owner's legal representative signature Site Re�isit Charge �t �� Date(s): 8 �i//Z� ClientNotificationDate: Da e � ' EHS: Sign given �Yes ❑No ,_.� '/ �� ��� Account# U!d Revised 11/06 ���}�"� ���� V � Invoice# ,' , ���� ��t �OC�1 Go:VIl:�PS -.Davie County NC Public Access Page 1 of 1 Davie County, NC - GIS/Mapping System j �'�m�� Click HereTo Start Ouer Quick 5�earch;�(Count3r ID t " +F .- �� � `� n� �kctiue LaXer. ❑lfs��'�laA +PS ��rs *..' �, � o� .."' 0 PAR.sELS (Map Tip�Availablel *r ��t t�+� .:��. � h4�� ��r�^��s � I�e�ults � � �� _..Y_ .. .� I 4 "�,'�� .���,�+��'�'�, . _r _.�� .,�._ �;>.._.� '� �- �'�-k� ��� "��`�� �" - �, r, �" �( � ��� �� �� � � �,�� � � ��� ��. �, r �� r t � �c ' i1: . � ��� 1rM a.���.. .� �� '��f .' �Yc; �, i ` , :��k ��a, ik.� , ,� � � �� b' g � "i��'�� � ,�e,eJ ��s�� '� . � N� � � ; � c� �1 a, . _�,� � � , a�z �� �,� � � .. , : , , . ^i. g a '� � � �s d y ..N ��� � af, ♦�'�- �'+� . �s� �� gW � � � Ei '�- '�' �tiq �. 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' . _ � 4 R I,, 1 Nq,�,.: � �.�- -� � �d, a�+,^ . 6' ^"� . . �. _ ..� .�pp`3 http://maps.co.davie.nc.us/GoMapshnap/Index.cfm?mainmapservice=gomaps&CFID=412... 5/12/2008 w - , . , , , ' � � ' Davie County Environmental IIealth P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990005068 Tax PIN/EH#: 5718-93-5380 Billed To: Mary Hall Subdivision Info: Address 720 Lakedale Road Location/Address: McAllister Road-27028 City; Colfax, Property Size: 22.431 Acres 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 constructiori/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 lans,plat or the intended use change: / , __---- Pemut Type: ew ❑Repair �Expansion Pemut Valid for: Q'S Years ❑No Expiration Residential Specifications: #Bedrooms #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):�(.(,� Type of Water Supply: ❑County/City C�Well ❑Community Well AS stated in 15A NCAC 18A.19S9(,�i� Site Modificarions/Permit Conditions: accepted Svstems rna� �ISo hP �� S stem T e LTAR Inirial c c Re air 1-e. 7 H Site Plan �� �/ ( �5G�P p r oY � �oute �, --� �I � �/� �- � `2� .a0�'i �t, c� — `n ai,f, �� � 4'+e// .-� G �' ��, �„ r .rX � ` J'� � � � � . J . �a � � � �.. � , r�� ys , � Environmental Health Specialist Date �7 — � i.p.l l-06 ,04/211200B 13:37 64I�24051 FIRST CITIZENS BANK PAGE �2/�6 •- __ . . . �� _.. , �.{� �� .: `V � � `;.;�y�r,: �4PP .tti: ION:F.OR..SI'I'EEViI�,UATION/TMPROt/E,VtL-NT P.�RMIT&.ATC � , `Z�� Davie Cot�nty Environmenral Health �`� :���, � Z 1 P.U.Box R48/210 Hnspitnt Strcct ` i �, PQ • b��ckev;itc,hC 27028 �� ��,� (33G)751-$7fi0!Fn!c(33G)�St•8786 l� c��������ti4� ��»�c�ay,�� ..n!'ur. ";tc . �;�Mimpmvcmcnt PeiYrrir � huehori»rinn�To Cnn.euct{nTC)._ f3u�h.. Q pcnP'.�ppli�;rlion: . cu , xii�:+ngSystcm �.zransiun�MOA�f�eationaCL•xigzinRSystcmorFncility :`.:IMPO�I"�SPl7"'THt,S APPLICnT�nN CANM1'OT ltF.ARfX'ESSED UNL�.SS'AI;L:OF'PHE RTQt11REU - M1'ORMATION tS PROuIDF.U, RtCer to thc INI�ORbSAT1C7N BOLCL-T1IJ fnr intilruct'tonx. APPI,ICAVT INFORMATION _. _. . . 1iVumc tQbe B;1fcd. �' , . .��. . . . - • GhssctP-crsnn. (` . .(3illing Add�ss. (� r—�� Homc Pitionc.3Rl�_� ' ; City/5tatc/7.1P , .�/r�f"5 [3sii�ess Fhone�j " ' �ame on PcrmtvrtTC i£nr'ffe�rat th�n Ahove -hfatli+tg Addtcsc _ _ C}�IStacc/Zi ._ PROPEftTY iNFORMATION •Dnfe HovselFacitiF Comcrs Fla cA ` '! r����� NOTF.� A curvty pint or�iEC plall tttU3(ateompdtly thiS xppticu[iort. ��oludod: SttC Pisn ?la!(f0!eaic) {Fcmtiti vafidfprGQmortth� iNi itcpla �noespir iort+�'ithMmt�letep111,) / r� , nwnc,Y-S Ne,i��c� ,a . ��-I. Piy ne hcr..���(�Z=�L�� Qµncr's�hddrc�s n1�--.-_aY(St�etc!"1_ip_` ��.. Propeny Addr�ss ._ ; ,1` �Y��C�►� Lot Sizc '?+�.. �.�j �':K���llc 4'S._�11.. -35,�.�_t'c�R.�� � .Suhdivision Namc(if-appluab�c 1 �ct�o�/Lott� �^ / .p ; � Dircct �ss 1' Site� �r � �� 1� � �. � t ..�ICCI1C:tncwc7.WiR1y0�IhC�6iI0wTI1�GS�tiOnSiy••yei,su(�orting_ttOwntcMati mtrsrtrc�attathcd. . � Aie purc any uistingwattcw¢;CrSystcros cm khtSite' YeS. _ _ . :p��.tlsC.S��c centain jure�dictionn)wetl�nd.+? Y¢s � , , A,rc thcreanyC��temcnes ar righ;•o7=w�y�on 1hd S�ic? YCS o • is thc si�c vubjcet w approvt;Cy anptl�er putii{c ager�y^- Ycs ,o . ..wifl wackwaacr othcr Ihan cSnmcs;iC>c.v�gF��e. rneratcJ.^ Yec. Nu (F RESTpENCE FlLL OUT TFI�BOX�L-LOW N Peo �c �t flCdroom5 N B3thC00tttg Z Gnrden7ttWWlrirlpnol .Yes o. Daccmrnk C�0 S�e¢�ncnt P1u?ftbi:l�t Yes -No � � � 1F NON-RES1DElYCF,FILL OUT TFtF QOX BLI.qW Typco�Facitiey/Bttsincss '1'oc�.ISq�.�arcFvokiFcnfBuilding sPeopte �S Sink; tt Comnxxics -k Sl�owcrs -#Urinais . Es[imati�'Wacertissgc(g.{tens 9cr�l+ry}�- (Atiaclti documcntation of.similar facility wStCf COtlsumpci0n) .FODDCF..RVICEONLY: �!Scats Typc ayxtcm rCques�ed� Conventiona; Acccpted hmova!iih AStcm9tivc OI1��� _ ...........__....__..._......__-------'---� _...._•---.�...-....- ... ... , .... • W�ter Suppiy Typc' CountvK'iIy W�ter New WcII F.xist'trg WdV Communi�y wot! ........ ............__..,.,,�,,.m ...,. . Ck>yvtr a���iC�pxtc adclitions ur cxransions vf ihc lacility:his c,ciem ic in:cndal 10 ceivc? Yes No' lfycc,whattypc! , _ ,:�___ �...._..._.__�..�...,..____--�....,..,. „_..,..,.,,,..,,.,,.,,...�.....,....,_.._,.,.......,._.�........_...__�.____.._._......,-..._..._._..,__....,.,..._......_.__...._....................�_...__, `I"ilis is to-�nti Fy�hat thc irlCultlu[!nn p�uviJed on�hiv¢Rplicatiott ia truc anii corrcct to thc bcst uf nty'knnwtcdb�1 un�inttarcd Utnt any r�rmil(5)"br/1TG'(sl�i�eucdl�crcafter arC mhjoct to sc�cpc�tSrt+n�w+c�ac.�Sidrt�liHe sitc is akt(Cd.thc intcndCdyte.. cha��cc nr it'ehc�ntormat�on su6mined in ih�s�ppliwtion is�.+ls�fied or ehungal. 1 hereby grant nght otentry to lh�Au;horizod ; kepre.�enc�tiv��I'the D��+e C�unry Fiwlth 17epnrtvnent tu eoncluct necessary inSpcecinns to Jeterm�nc compii�ree���tb a�iiica6le latvs T��d ru1cF, I uttclCrs:anA tha!l amte�pon�iblc C��r thC p�Pp�T idcntifitatiunanQlabcFingoE�xrtylinca an�epniarc.and.i locating antf fl3gginQ iA hnus�G+Ciliry. .lcxation..propcsa���clt lacntion and dm tacation ol+�y nchcr omcnities. ,. .... __ ._ .. l�� Site Roviait Cnerg� PrOp:It �wn '. cuau�nC Fni rcpn:sCnt�tivc�ionaturC ,. Uutc(s): _ L . __ riicnt�IiGfcar,tniTUatc:. � ^�- Q�- , . ..e� .�D _ t)ai�. . EFIS' ' . Sign givcn YCe \o ' Accaunt# �� }tav�aed!I/OG ..Imviet;- ���\/v , 04/21/2608 13:32 3364124051 FIRST CITIZENS BANK PAGE 03/06 . , . , . . -�'���L_1..Fi��.._ ---�--- ----... ... ,_. . _...,..._ � .i : __ ; , � �.. .._,,� . . .. ._ .:.� _. : �e. _ ; . . _� . ... �. . _ _. , r ; • !. _ . _ � a ....... . ... ... ..... .. . . M. ....• . � . � . � . .. .�� � � �. . . . . .. � . � . . . .... .. .. .. .... . .... . . � . ..� .. . .... .. .. . . .. ....I.... • �..�... ..... . _... . .... ...... , . . .. . . . .� . ._ .. . . . . . . . ....�.... � • . ... . . .,.. � ..,..�. .... � . . ' � ..... . .. .. .. . r. . .._ �. . .._. .. , . � , . �.. .._ _ _. �.��._ ., .:���, _ _. � � ._ . .__ _ n ,c,... ._ � _ .. .. . , , . . _.. . �.. - . _. . . _ .� '}'B' . _._ .. ._ ... . .._ . ...o _ �.. .. ({I �. � � .. (� . .. .. _ _ ..�i � - .�.. �. _ .._ . ' . . _: •, .�. � �.. . .'�. � �. � � � � .... ... .._ _. ... . _�... .. _, . _1 � .. : , _': �._ .._ ._. ._ . ._.. � �._ ___ _ _.I _.. . __ . _. . . �. . _ .` .. _ � � _DRtV� _ _../ _. , W,��.. � �,:_. . ... , .. _ _ , ... _ .� _ . _.. . .. _ _ _ ._ �_�' _ _ . . � ��� � _ 1 � . . _ . _ . � � . , . . _ _ _ ._ , �. �. _ ._ . _ ��'_.. ��� _ _ _ _ . � ���_. . _F� , . f . � � . . .. ... . . ... �(.. i .. . . � . .. .. . . .... . � .. . - .. ...� ...... .... ... . ;.� �� . .. .. .� ...... ... . . . ._ � .. . _7`� .. ..... ... .... .. . __ . � M . ...I� ,....I . .... . � .... . � . . .., . .0 ........ ..... .. � .� .. � � . ..._...�. � '. _ �(. . _ . +� � , . � ' • " ' ' � ' � DAVIE COUNTY HEALTH DEPARTMENT Environmental Heaith Section Soil/Site Evaluation APPL I F Tax PIN/EH#: 571�����iNFORMATION Billed To: Mary Hall ' Subdivision Info: (�7/�-93- 'Jr3$D Reference Name: Location/Address: McAllister Road-27028 � � D� Proposed Facility:. Residence Property Size: 22.431 Acres Date Evaluated: '�� 7°� . - �d �o,l�5 �"� l� _ d� , �5 � 9 � __. l � .�2�� ?j 4 — � v —v O _ �� � Water Supply: ' On-Site Well _� Community Public Evaluation By: Auger Boring Pit ./ Cut il-�� FAC'TORS �� 1 �L ' 2 �dy ' s 3�A 4 ' 6 7 Landscape position L_ . L � L L-- �.- . Slope % ` HORIZON I DEPTH � G— Texture grou � . G '� Consistence Structure j • �L, Mineralo ' � HORIZON II DEPTH ' �� " t Texture rou ' � • Consistence Structure � Mineralo HORIZON III DEPTH • Texture rou , Consistence Structure Mineralo HORIZON IV DEPTH " Texture rou Consistence S tructure • � i Mineralo !� SOIL WETNESS �� v/ �b / lr /- RESTRICTIVE HORIZON � .�. • �• c• /-- SAPROLITE , �,� ; , CLASSIFICATION LONG-TERM ACCEPTANCE RATE Q+,7 , , , �. SITE CLASSIFICATION: � � EVALUATION BY: � 'Vt �_' LONG-TERM ACCEPTANCE RATE: d �� � � OTHER(S)PRESENT: ��,�✓�� �Q l.�—P REMARKS: �y� 11 LEGEND . I,�ndscane Position R-Ridge S -Shoulc�er L-Linear slope FS -Foot slope N-Nose slope CC -Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Tfx� . 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-Silry clay C-Clay ��N�r�T .Nc . 1?�Qis.c VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � ' • NS-Non sticky SS.-Slightly sticky S-Sticky VS -Very Sticky _, _ NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic StrLctLre SC -Single grain M -Massive CR-Crumb GR-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralo�v ' ' � 1:1,2:1,Mixed �otes 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 r�rur�nvn� �n�..:..,,a, Gc�V;rJP� -i�auae County NC Public Access Page 1 of 1 Davie County, NC - GIS/Mapping System r ���L�r� �Cli�k HereTa Start Quer Quick S���rth:�C€s�rit}� ID t ___.... ... 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DISINFECTION:Type Amount �cLd /�aX�!'�?S g. WATERZONES(depth): Weq dor(tnd'nriduanName � � • Fram�To . From To 6Gt/�!'t)- �l� /Z/��/NS From��d To� From To WeA Cordrecmr Comparry Nama Frotr� To From To STREETADDRESSy�7 U fi�i�/�lS /��//��/u� 7. CASIN6: ' Thidmass/ �_�1�(/��Lt IZc_ � C. z ��'y 7 From C� �To�_5��. Ft D�.2� We��c �F'1f�� �r T � ��te/ � 77 T�p Code From To Ft From To Ft A7ea r;ude- Phone rntmber 2 WELL WFORMA710N•� � GROtJT: Depth Matertal Metlwd $iTE WELL iD�{'dappiicable�, FrortL�To� Ft�', From�_To�C3 ,,. ' VIlELL CONSTRUCTION PERMIT# From To Ft. OTNERASSOCIATEDPERMI7�(dappGcable) 9. SCREEN: Depth Diameter SIotS'¢a Mat�eriai 3.INBLL USE(Chedc Appticable BCo/x): ResideMial Water Suppty p� From ' To Ft in. In. DATE DRtLLED �i"� '� ' �D _ From To Ft in. iR TIMECOMPLETED �'�i L� AMU PMB' From To Ft in. in. 4.UYELL LOCATlON: 10.SANOIC3RAVEL PACK: CRY COUN7Y ��UI� Depth S¢e Material � /Yfl� jZ /��� From To Ft From . To Pt (Street Name.Numbers.CommunTty,SlibdNision.Lot Na.Pa�el�p Gbde] From To Ft TOPDGR14PHIC/i.AND SE7TtNG 8 51ope !,Valley � Flat ➢ Ridge 9 Other ' (chedc eppropriate twx) 11.DRILLINO LOG d � g �Y�ma�, From To ormation Description LATITUDE 3� ,�i.f�� a9/,� minu�s,sxondsor G� � rr C�..•, LONGtTUDE� � � `�/� in s decimal fotmat _ c?. �� Latitude/longitude source: o GPS e Topogaphic map (locafion ofweQmustbe shown o»a t1SGS fopa map and attachad to thlsl6mt ifnot nsing GPSj 6.WELL OWNER OWNER'3 NAME��Ft��r c /Z ��� STR ETADDRESS ' O J7 f fZd �o��au 11� � z? Z35 Cily or Town State Zlp Code c 33G- ��z - SFoBy Area cade- Phone number ._ 12 REMARKS: . 6.VYELL DSTAILS: �+►, a. TOTAL DEPTH: �V'.� b. DOES YYELL REPlACE EXI5TING VYELL? YES U � i oo Ne�er c�rmr-rTtwr'rH�swa.�was cavsTRucr�mt acc�an�c,�wm� � � C. WA7�RLEVELBBbWTO ofCasin . Q FT. 15ANCAC2C. 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