HomeMy WebLinkAboutWELL-03-2016-070034.TIF �gA CATAWBA COUNTY Case#•
is a Public Health Department Subdivision CRESCENT LAND AND TII•
Q�.� Environmental Health Division PIN# 460715648398
in till `c PO Box 389, 100-A Southwest Blvd,Newton.NC 28658 LOT# 123
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NAME ON PERMIT: JAMES & NANCY PIRTLE, 4553 BRAVE AV, MAIDEN NC 28650
Site Address: 3825 CHEVLOT HILLS RD, SHERRILLS FORD NC 28673
Property Size: Square Feet:37,461.60 Acres:0.86
• Directions: Hwy 150 to Cheviot Hills Rd (right before Slanting Bridge Rd when coming from Hwy 16 Denver), Pass 3 roads
on the left& road will curve to the left& it is a vacant lot on the left.
Owner/Authorized Representative Acknowledgement of Permit Receipt
I certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
property described above.
As the property owner or authorized representative, I have received the above referenced permit(s) as
N( requested in the application for service RBPR-02-2016-23163 by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
d Electronic Image Transmittal/ E-mail (Return receipt required)
NrAs the property owner or authorized representative I have reviewed and understand the specific conditions
of the permit issued, and further understand that all applicable regulatory requirements specified under the North
Carolina Laws and Rules for Sewage Treatment and Disposal Systems (15A NCAC 18A .1900), and/or
Well Construction Standards (15A NCAC 2C .0100), shall apply to the issuance of this permit and the
construction of the wastewater system and/or water supply well permitted.
Permit Issue Date: 03/14/2016
Owner/Authorized Representative Signature
Date
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit trans, itted by Ai_t A Li it, El (name of person sending permit)
Signature ,_.A1104 f ,v a Date/Time30/(40 010:
Method: Fax \lEmailUS Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
r
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ehpennit 03/14/2016 09:35 Page 4 of4
• CATAWBA COUNTY I] � ro Case# WELL-03-2016-070034 CI r Public Health Department Subdivision CRESCENT LAND AND TIA
� Environmental Health Divisions .y PINK 460715648398
CI" Y PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 � GO; LOT# 123
r` sy `t
CI '-'5I=1.
NAME ON PERMIT: JAMES & NANCY PIRTLE, 4553 BRAVE AV, MAIDEN NC 28650
Site Address: 3825 CHEVLOT HILLS RD, SHERRILLS FORD NC 28673
Property Size: Square Feet:37,461.60 Acres:0.86
Directions: Hwy 150 to Cheviot Hills Rd (right before Slanting Bridge Rd when coming from Hwy 16 Denver), Pass 3 roads
on the left & road will curve to the left & it is a vacant lot on the left.
WELL PERMIT
WATER SUPPLY: Individual Well
SETBACKS:
1. BUILDNG FOUNDATIONS 25 FT.
2. EXISTING & PROPOSED SEPTIC SYSTEMS MIN. 50 FT.
3. EXISTING & PROPOSED SEPTIC REPAIR AREA MIN. 50 FT.
4 . SEWAGE PUMP SUPPLY LINE 50 FT.
5. UNDERGROUND STORAGE TANKS 100 FT.
6. STREAMS/BROOKS/CREEKS 50 FT.
7. LAKES/PONDS RESERVOIRS 50 FT.
ALL OTHER POSSIBLE SOURCES OF GROUND WATER CONTAMINATION 100 FT.
The well driller must verify all setbacks before drilling the well.
If the well driller is unable to maintain any of the above setbacks,
contact Catawba County Environmental Health at (828) 465-8270
before drilling the well.
Grouting Depth: Minimum 20 Feet
Casing Height: 12" Above Land Surface
All newly constructed private drinking water wells are required to be sampled in accordance with the North
Carolina Rules Regarding Private drinking Water Well Testing (15A NCAC 18A .3800). The fee for this
sampling is included in the cost of the well permit. It is the applicant or property owner's responsibility to
notify Environmental Health when the well is ready for sampling.
Water samples will be drawn from an outside faucet unless otherwise specified. Please note that all water samples are
taken during one visit. The processing laboratories have different protocols and timeframes for reporting results;
therefore,you may receive several different reports concerning your water sample. For questions or more information,
please contact Catawba County Environmental Health at(828)465-8270.
Jason Boyd 03/14/2016
AUTHORIZED STATE AGENT APPROVAL DATE
ehpermii 03/14/2016 09:35 Page 1 of 3
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