HomeMy WebLinkAboutEHPR-04-2015-21234 (2).TIF
/ I, JO.5 CATAWBA COUNTY HEALTH DEPARTMENT
(/l ~' Telephony, (lJ78r465.8.Z~1O;cnD: (828) 465-8200 N2 ,~;)}
IP ~c~ PrInt. . ~r P;m1._L-sYs, Type....!Jf...2:....Well Pnnt._Replacement Well Well Rpr. pnnfl
Owner/Agent _~ If:, tI~ SUb;~~s~~n Ij,( E2 t~
Address :5 0 J. - Section/Block/Phase Lot# ? f
Lot Size .5~irections: II> r..U ~ /~g .L...~_ u.;;;;;;; ~ OJi L:..
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Property Address - f '/-#1"''7:1'
Facility: House~Mobile Home_ Business_Multi,family_ . Other: Pin Number ;3[, 1I9 Cl~ '18' f?v.?!j"
Other . Zoning Approval # :Z" 0 III , Ii"" '
# Bedrooms # Seats # Employees , Application Rate , I-( GPD Flow ifYCJ
Hot Tub or Spa sino Special Fixtures Basement ye@ . 100% Repair Area@lO -' ____
Basement Plumbing yes/no Water Supply: Pnvate Well_ Public~emi,Pubhc_
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Type of System: Trench_ Bed_ Pump_ Pump/Panel_ Panel_ LPP _ Other ~ ')..S"J.~ ~~
Septic Tank Size / e~ 0 p~mp Tank Size Nitrification Field: Total Square Feet tJ 0 () Depth of Stone N./-?L
Bed Size ., Trench Width c3 Total Length of All Trenches .? 0 () Number of Trenches...:s ,
Trench Length ~/~//OO 1_1_1_ Feet on Center t) r Maximum Trench Depth J p rt" Distance of Nearest Well #0
'DO NOT INSTALL SEPTIC WHEN WET' 'WELL RECORD REQUIRED AT COMPLETION'
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Topo:J-S Slope I
Texture I
Structure I
Clay Min. I
Soil Wetness I
Soil Depth IY I
Restric. Hoz, a I
Available spac I
Overall Class U I
Comments: I
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Inches deep, I
"NO GUARANTEE OR WARRANTY IS IMPLIED OR GIVEN AS TO THE PERFORMANCE OR LENGTH OF TIME THIS SYSTEM
WILL FUNCTION"
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Fllter Required
Riser required when
tank is more than 6
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*lmprovcment 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 (5) 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 t any site by the lIealth Department, /2 A./1_, _ ~ c-
PennitDate - 00. EHS fi,.:~~ "'/1~O- /t-.Jr
Owner/Agent Septic Tank Installed By . ~<.f::> Date;'''...;! .,.-qJ
EHS Well Installed By Well Gront Approval Date
Well Head Approval Date Date Sample Collected
Date of Resnlts Results EHS
White - Office Blue - Building Inspection Operation Permit Yellow : Ow~rl Agent Green - Building Inspection Authorization to Construct