HomeMy WebLinkAboutWELL-04-2016-071593.TIF V 26 2016 07:59PM Hickory Well 828.397.6701 page 1
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!=. CATASBA COUNTI' Case WELL-04-2016-071593
t + Public Health Department, Subdivision
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j Environments! Health Division PIN» 372515546611
Sin W PO Box 389. 100-A Southwest Blvd,Newton,NC 28658 LOT*
NAME ON PERMIT: SEVEN HAVEN LLC, PO BOX 1581, HICKORY NC 28603
Site Address: 5045 16TH ST DR NE, HICKORY NC 28601
Property Size: Square Feet:81,892.80 Acres:1.88
Directions: Right off Sandy Ridge Rd, Turns into 16th St Dr NE it will dead-end into a single lane asphalt road, 5045 is
3/4 mile on the Left.
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` Owner/Authorized Representative Acknowledgement of Permit Receipt
1 certify that lam the owner or authorized agent (owner's authorization required) representing the owner of the
property described above.
L/As the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service EHPR-04-2016-23583 by the following method(s):
Received in Person
irecsimile Transmittal (Return form with signature required)
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 (ISA 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: 04/26/2016
��wner/Authorized Representative Signature /�G/CO(y £d 6- /)/d(GC//tr ��
(((((( Date /uv//e // ` /.1`rs' 72
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
1 t It
Permit transmitted by , , (name ofpersor end'ngpennil)) I
SignatureYL Date/fimc� Lob`
Method: Fax \/Email_11S Mail Other
Owner's request to send b the above indicated method of transmittal in lieu of signature
\1 tia IL
We want to h ar from you. Please take a few moments to complete our customer service survey at:
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ehpn°111 D4/26/2016 10:35 Page 3 or 3
,rsA CATAWBA COUNTY Oil on CI Case# WELL-04-2016-071593
Public Health Department • ' • . ... • Subdivision
2 dirt o M Environmental Health Division ; ti • • PIN# 372515546611
1� PO Box 389. 100-A Southwest Blvd,Newton.NC 28658 • ° ....103
• In. LOT#
1842 w •4
ri. i•
NAME ON PERMIT: SEVEN HAVEN LLC, PO BOX 1581, HICKORY NC 28603
Site Address: 5045 16TH ST DR NE, HICKORY NC 28601
Property Size: Square Feet: 81,892.80 Acres:1.88
Directions: Right off Sandy Ridge Rd, Turns into 16th St Dr NE it will dead-end into a single lane asphalt road, 5045 is
3/4 mile 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 (I5ANCAC 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.
Steven Price 04/26/2016
AUTHORIZED STATE AGENT APPROVAL DATE
ehperniat 04/26/2016 10:35 Page I of:3
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