Loading...
HomeMy WebLinkAboutRBPR-03-2015-21108.TIF- - - ~' ~ CATAWBA COUNTY HEALTH DEPARTMENT .~_ Telephone: (828)465-8270 TDD: (828) 465-8200 WLS # ~ ®U.3 -0 a3 g.Z IP~AC ~~( Rpr. Print. Opr. Print. Sys. Type ~~~~ Well Print. Replacement Well Well Rpr. Print. Owner/Agent Il ©/~ ~,~ / yr~ ~ i4-~'1~ y Phone Address ~ Q g Gtt 2r11S ~j~ ~,,,Z! ~ ~,~t-E'i/~ Subdivision /-~ ~r~~. y~ yy~if..~, C-".S=T,~'~ ' a .v Section/Block/Phase Lot#~ Lot Size 3 . Z 7 gc.,'~SDirections: /D /~ d~ i . fr, ~. v ~RLt/.S r~s~f /~'P)~.1~ ~ -j~/S'~/'~/~/r6.5' 1n-~7~D I@.~ 1¢,,i~ ` Property Address J d 8 Facility: House~_ Mobile Home Business Multi-family .Other: Pin Number `° Other .Zoning Approval # O ~®d,,~' .. Q ~ # Bedrooms_~~ # Seats # Employees .Application Rate GPD Flow ~ ,(, C'~ Hot Tub or Spe no Special Fixtures Baseme es o .100% Repair Area es no Basement Plumbing~,no Water Supp y: Private Well Public~~ Semi-Public Type of System: Trench~_ Bed ~- Pump- Pump/Panel Panel `- LPP =~ Other Se tic Tank Size ~ P ,%00® Pump Tank Size a--~-~ Nitrification Field: Total Square Feet /`Gl,~ (~ Depth of Stone~^ Bed Size Trench Width ~ o To engtkl of All Trenches ~y,$~ Number of Trenches r// Trench Length~~//- Feet on Cent ~ Maximum Trench Depth ~~ `f Distance of Nearest Well *DO 1~10T INSTALL SEPTIC '~IHFN WFT~. ,t~ `~T~%FLL RECORD REf~UIRED AT C014iIPLFTION* **********************************~***~***~******~o.~*,~J****************************************************************** Topo % Slope ~ Texture ~ Structure ~ Clay Min. ~ Soil Wetness ~ Soil Depth ~ Restric. Hoz. at _" ~ Available space yes/no ~ Overall Class S PS U Comments: ~ .S~ ~S,G-/L ol/L-~ n, yy.s /~i/f~C, ~ 6 ~7'C3 - ~, a~a I I I I I Filter Required ~ Riser required when tank is more than 6 ~ cc~en.~s inches deep. ~ _ e.~ **NO GUARANTEE OR A WILL FUNCTION** ~~, ?~ Ic / (~ f ~~ 'b~~~ V' ,, ~vq' g~ IS IMPLIED OR GIVEN AS TO THE PEKt~ORMANCE OR LENGTH OF TIME THIS SYSTEM ************************************************************************************** *Improvement Permit has no expiration date and is transferable, but may be revoked if site plans or intended use changes for the proposed facility. An Authorization to Construct is valid for (~ five years from date issued and is not transferable. Well Permit valid for 5 years provided site conditions do not change. Well location, installation, and protection must meet state and local regulations, and must be inspected and approved by a representative of the Catawba County Health Department before any portion of the installation is put into use. The siting of the well by the Health Department staff is to provide protection from known possible sources of contamination. No volume of water is guaranteed at any site b the Health Department. /~ Permit Date ~/ /' EHS ~ - ~ ---~ iC _ ~a Owner/Agent Septic Tank Installed By /~}- ~- /A~~ ~5"~e ~ C. Date -1~- a~ EHS Well Installed By ~,1 Well Grout Approval Date Well Head Approval Date Date Sample Collected Date of Results Results EHS ~,~ .~--~-~ White -Office Yellow - OwnerlAgent Pink -Building Inspection Authorization to Construct