HomeMy WebLinkAboutWELL-04-2016-071073.TIF tgA CATAWBA COUNTY Case#
C7' pit Public Health Department Subdivision
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�, Errvtronmental Health Division PINK 368601250307
�� PO Box 389, 100-A Southwest 13Ivd,Newton,NC 28658 LOT# 1
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NAME ON PERMIT: MICKEY COOKE, 1803 HEWITT RD, CLAREMONT NC 28610
Site Address: 4739 KENNETHS DR, MAIDEN NC 28650
Property Size: Square Feet:60,112.80 Acres:1.38
Directions: E Maiden Rd to Kenneth Dr& Hwy 16
Owner/Authorized Representative Acknowledgement of Permit Receipt
_ property certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
described above.
As the property owner or authorized representative, I have received the above referenced pennit(s) as
requested in the application for service RBPR-03-2016-23390 by the following method(s):
Received in Person
1
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/ E-mail (Return receipt required)
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'1/k As the property owner or authorized representative I have reviewed and understand the specific conditions
o 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: 04/12/2016
, Owner/Authorized Representative Signature 4 �� ;
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Date
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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 04/12/2016 10:53 Page 3 of 6
w3 CATAWBA COUNTY 0 ''- R:. 0 Case# WELL-04-2016-071073
.T .t L Public Health Department . ` . J Subdivision
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NAME ON PERMIT: MICKEY COOKE, 1803 HEWITT RD, CLAREMONT NC 28610
Site Address: 4739 KENNETHS DR, MAIDEN NC 28650
Property Size: Square Feet:60,112.80 Acres:1.38
Directions: E Maiden Rd to Kenneth Dr & Hwy 16
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 I8A .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 04/12/2016
AUTHORIZED STATE AGENT APPROVAL DATE
ehpermit 04/12/2016 10:54 Page I of
"PA,, Permit 1< 1 KBPR-3-16-23390
CATA�Vth COUNTY Name Mickey Cooke
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. PO Box 389, IOOA Southwest Blvd, Net�2on NC 28658
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Site Plan Improvement Permit
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