HomeMy WebLinkAboutWELL-04-2016-071598.TIF 4 p CATAWBA COUNTY Case#
111 , Public Health Department Subdivision GEORGIA PARK
< im, oe YI Environmental Health Division PIN# 366703233105
� _ PO BON 389. 100-A Southwest Blvd,Newton.NC 28658 LOTH 8
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NAME ON PERMIT: CLAYTON HOMES, PO BOX 132, TAYLORSVILLE NC 28681
Site Address: 3453 MELDONNA DR, MAIDEN NC 28650
Property Size: Square Feet:20,037.60 Acres:0.46
Directions: Hwy 16/left Buffalo Shoals Rd / right Meldonna Dr/ lot 8 on left
Owner/Authorized Representative Acknowledgement of Permit Receipt
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I certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
property described above.
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As the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service RBPR-02-2016-23282 by the following method(s):
in
V 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: 04/26/2016 �Q
Owner/Authorized Representative Signature �✓✓ 0 0 �C d""d)
Date gjpi( Le
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name ofperson 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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ehpennit 04/26/2016 13:19 Page 3 of 3
v A CATAWBA COUNTY 0 oil 11' .S 0 Case# WELL-04-2016-071598
at'y Public Health Department � ! Subdivision GEORGIA PARK
`-1! Environmental Health Division • ' PINK 366703233105
N.it PO Box 389, 100-A Southwest Blvd,Newton.NC 28658 _� i P � '� LOT# 8
1842 :. t . -
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NAME ON PERMIT: CLAYTON HOMES, PO BOX 132, TAYLORSVILLE NC 28681
Site Address: 3453 MELDONNA DR, MAIDEN NC 28650
Property Size: Square Feet: 20,037.60 Acres:0.46
Directions: Hwy 16 / left Buffalo Shoals Rd / right Meldonna Dr/ lot 8 on 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 (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 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.
Robbie Phelps 04/26/2016
AUTHORIZED STATE AGENT APPROVAL DATE
ehpeunit 04/26/2016 13:20 Page 1 of3
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Parcel: 366703233105, 3453 MELDONNA DR 1in=40ft
MAIDEN, 28650
This map/report 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 arses or may
arise from this map/report product or the use thereof by any pemon or entity_
Copyr Wit 2014 Catawba County NC
04125/2016