340 Speaks Rd .r . � Davie County Environmental Health
. � P.O.Box 848/210 Hospital Street
'� • Mocksville,NC 27028
� (336)753-6780/Fax(336)753-1680
WELL PERMIT
Accou�f #: 990005341 Tax Pif�€.%EH#: 5852-30-3744-Weil
Bifl�d 70: Ellison Armfield - Suf�divi�iori lnfa:
Referer�ce N�n�e: LacaiianiAddr�ss: 340 Speaks Rd-27006
Propos�d Facility: Residential-Well Pfo�erty Size: 20 acres
ATC Number. 006Y. - ' • -: �
Actions of the employees of the 17�avie 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 facdcircumstances upon which this permit was issued.
Permit Type: New�- Repair ❑ Abandonment
,v�(�✓Proposed Well Location Dia Certific ���ipletion Diagram n Q,(
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Comments: / ' T' �l�Y� Driller: e«��9Ki.
� i� Certification#: � � � '�
� u Grout Inspected: ^ v�-.7 '� (
r Well Head Inspected: � d l/�1' �
GPS Coordi e .3 5� �- (o � � U(J •�3�
EHS. Date: "'� ^� EHS: ate:
W.P.7-08
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' �,�P, LICATION FOR PRIVATE WELL PERMIT
� . ?� — �-�� Davie County Environmental Health
� fi
1a'�� �' P.O.Box 848/210 Hospital Street
A �uV � 3 � Mocksville,NC 27028
1 ��,4 (336)753-6780/Fax(336)753-1680
0
***IMPORTANT'°**
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name ���1; s a.-.' -.'��-� Contact Person S.�t w---
Address � `i o Sn e ,�{;g 12 Home Phone 3� (, 9 y I 3 �. � 7 '
City/State/ZIP �q�p���,,��� � � ���o � Business Phone
Name on Permit if D�erent 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)
Owner's Name ����; r a., � :v.-. f,'.: �- U PhoneNumber
Owner's Address 3� � ��� Sn ,,a r t iL� City/State/Zip�� v e,,,.�. �q � �7 a o
Property Address 3`1 o C��.. rs 2 1 City�4�.1�,„`,,
Lot Size 2 0 � � ;-�� Tax PIN# S�SZ-36�.�7��
Subdivision Name(if applicable) Section/Lot#
Directions To Site: / r a' � �, 20,� ��� �E- .�4�� 1 s �I a- -1�1..._,_
� S o .,� r, �
DEVELOPMENT INFORMA ON
Permit Type: New Well�� Well Repair Well Abandonment Other(specify)
FacilityType: 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
determine the best location for a well.
�� �
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Signed Date
Site Revisit Charge
� Date(s):
Client Notification Date:
EHS:
7/30/09 � Account# �r.s"��
Invoice#
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http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=gomaps&CFID=4129... 8/3/2010