HomeMy WebLinkAboutWELL-03-2016-070300.TIF , , • CATAWBA COUNTS' Case# - __
C'41111. Public Health Department Subdivision
a Environmental Health Division PIN# 461601291353
Vie"-.4 PO Box 389, 100-A Southwest Blvd,Newton.NC 28658 LOTH
NAME ON PERMIT: JEFFREY SKIDMORE, 7981 BLUE WATER CT, DENVER NC 28037
Site Address: 4460 DERWOOD DR, SHERRILLS FORD NC 28673
Property Size: Square Feet:50,965.20 Acres:1.17
Directions: 16 S, Eon 150, TR Slanting Bridge, TL Drena, 1/2 mile left on Derwood, 2nd lot on right
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
perty described above.
As the property owner or authorized representative. I have received the above referenced permit(s) as
quested in the application for service RBPR-01-2016-23033 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
/ if 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: 03/22/2016
1/4.___ Owner/Authorized Representative Signature // ✓
Date c-yi`V/& /
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/Time
Method: Fax Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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ehpermit 03/22/2016 11:09 Page 3 of 3
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0)• • CATAWBA COUNTY 0 o 0 Case# WELL-03-2016-070300
3 Public Health Department _ ..ti Subdivision
< Environmental Health Division h' • ti .' •r PIN 461601291353
/Ky,i® PO Box 389, 100-A Southwest Blvd, Newton.NC 28658 G •.? LOT#
842/ - -- �- .
� o r.
NAME ON PERMIT: JEFFREY SKIDMORE, 7981 BLUE WATER CT, DENVER NC 28037 •
Site Address: 4460 DERWOOD DR, SHERRILLS FORD NC 28673
Property Size: Square Feet:50,965.20 Acres:1.17
Directions: 16 S, Eon 150, TR Slanting Bridge, TL Drena, 1/2 mile left on Derwood, 2nd lot on right
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 I-Iealth 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 (I5A 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 durint
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.
Robbie Phelps 03/22/2016
AUTHORIZED STATE AGENT APPROVAL DATE
ehpermit 03/22/2016 11:15 Page 1 of3
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Parcel: 461601291353, 4460 DERWOOD DR 1in=60ft
SHERRILLS FORD, 28673
This map/epon product was prepared from the Catawba County,NC Geospatial Information Services. Catawba County has made substantial efforts
to ensure the accuracy of location and labeling information contained on this map or data on this report.Catawba County promotes and recommends
the independent verification of any data contained on this map/report product by the user.The County of Catawba,its employees,agents,and
personnel,disclaim,and shall not be held liable for any and all damages,loss or liability,whether direct indirect or consequential which arises or may
arise from this map/report product or the use thereof by any person or entity.
Copyright 2014 Catawba County NC
03/21/2016
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