HomeMy WebLinkAboutWELL-03-2016-070524.TIF 4v,A CATAWBA COUNTY Case 4
t,_ Public Health Department Subdivision DOCKSIDE VIEW PH 4
�� 4 Environmental Health Division PIM# 460701363204
PO Box 389. 100-A Southwest Blvd,Newton.NC 28658 LOT# 25
/843 sm
NAME ON PERMIT: *FOURTEES INC, PO BOX 2429, DENVER NC 28037-
Site Address: 3651 BURTON ST, SHERRILLS FORD NC 28673
Property Size: Square Feet: 30,927.60 Acres:0.71
Directions: Sherrills Ford Rd to Mt. Pleasant To Burton
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
opproperty described above.
�, 11--As the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service RBPR-03-2016-23309 by the following method(s):
JReceived 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
Pof 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: 03/29/2016 t ,
Owner/Authorized Representative Signature
Date) C"I—K o
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (mmne 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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ehner,nit 03/29/2016 10:01 Page 4 of4
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y,A CATAWBA COUNTY 0 ; ,� a0 Case WELL-03-2016-070524
_ Y _ Public Health Department 4 r � � Subdivision DOCKSIDE VIEW PH 4
` r 173.
Environmental Health Division if.} 6 • } PINH 460701363204
�°•4PO Box 389, 100-A Southwest Blvd, Newton.NC 28658 i • LOTH 25
/A42 , t
NAME ON PERMIT: *FOURTEES INC, PO BOX 2429, DENVER NC 28037-
Site Address: 3651 BURTON ST, SHERRILLS FORD NC 28673
Property Size: Square Feet:30,927.60 Acres:0.71
Directions: Sherrills Ford Rd to Mt. Pleasant To Burton
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 I 8A .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 03/29/2016
AUTHORIZED STATE AGENT AI'PROVAI.DATE
chpermit 03/29/2016 10:02 Page 1 of 3
r Permit# RBPR-3-16-23309
CATAWBA COUNTY
Name Four Tees Inc(Tom Lawley)
Z Public Health Department Address 3651 Burton ST Sherrills Ford
U` �' Environmental Health Division
\\� PO Box 389, IOOA Southwest Blvd,Newton NC 28658 NC
1842
(828)465-8270 Fax (828)465-8276 TDD(828)465-8200 PIN# 460701363204
Site Plan Authorization to Construct
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