HomeMy WebLinkAboutWELL-03-2016-070035.TIF S$• \ CATAWBA COUNTY Case#•
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t, Public Health Department Subdivision CRESCENT LAND AND Tit
.�� Eewironmental Health Division PIN# 460715648398
.q1 / 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 l 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
•
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)
Electronic Image Transmittal/E-mail (Return receipt required)
As 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 '_O N�. - s , 101 (name of person sending permit)
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Signature ,.._111/ / � 116 Date/Time�3/1:4/( 69 10:t
Method: Fax \AmailUS Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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ehpermit 03/14/2016 09:35 Page 4 of 4
g' • CATAWBA COUNTY 0 . o..' - CI Case# WELL-03-2016-070035
;i:411 u Public Health Department ` � .ti" Subdivision CRESCENT LAND AND TIC
2 Environmental Health Division I ;I PINH 460715648398
•mfr- PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 ' o r _D f'
/g. wy} � � LOT# 123
I. , ..
1 i' .
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 ABANDONMENT PERMIT
Wells shall be abandoned in accordance with state regulations:
Article 15A North Carolina Administrative Code Subsection 2C
The Well Abandonment Report must be submitted to the Catawba County Environmental Health within 30 days upor
completion of a well abandonment.
Well contractor must schedule well abandonment inspection with Catawba County Environmental Health.
WELL TYPE
Drilled
Jason Boyd 03/14/2016
ISSUED BY PERMIT ISSUANCE DATE
ehpermit 03/14/2016 09:36 Page 1 oft
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