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HomeMy WebLinkAboutWELL-05-2016-072766.TIF ,B CATAWBA COUNTY Case# WELL-05-2016-072766 ^I`. ©l Public Health Department Subdivision ti < :uiv obi 4 Environmental Health Division PIN# 367803406676 PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 LOT# /8•'L ,u NAME ON PERMIT: HIGH POINT BUILDERS LLC, 5171 ELLEN AV, ARCHDALE NC 27263 Site Address: 4454 S NC 16 HWY, MAIDEN NC 28650 Property Size: Square Feet:20,037.60 Acres:.460 Directions: Hwy 16 S, on left past Layton Dr 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 property described above. As the property owner or authorized representative, I have received the above referenced permit(s) as requested in the application for service EHPR-05-2016-23939 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 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: 05/25/2016 Owner/Authorized Representative Signature Date Documentation of Permit(s) Transmittal (permit transmitted by electronic or other means) Permit transmitted by I; 1 �� 11S (name of person sending permit) Signature ���e 1 ( if 1 �A) Date/TimeT/Z\/�� @'!d`5o Method: Fax \/ imail US Mail Other Owner's request to send by the above indicated method of transmittal in lieu of signature We want to hear from you. Please take a few moments to complete our customer service survey at: http://www.surveymonkey.com/s/EHCustomer5ervice chpemiit 05/25/2016 10:24 Page 2 oft �� CATAWBA COUNTY Q o' r • Q Case# WELL-05-2016-072766 ,Qn� Public Health Department i• Subdivision < ��� . .� „/"l, Environmental Health Division r PIN# 367803406676 H PO Box 389. 100-A Southwest Blvd,Newton,NC 28658 •G � '� LOT# /gq2 s+ t D13 r a NAME ON PERMIT: HIGH POINT BUILDERS LLC, 5171 ELLEN AV, ARCHDALE NC 27263 Site Address: 4454 S NC 16 HWY, MAIDEN NC 28650 Property Size: Square Feet:20,037.60 Acres:.460 Directions: Hwy 16 S, on left past Cayton Dr WELL ABANDONMENT PERMIT Wells shall be abandoned in accordance with state regulations: Article 15A North Carolina Administrative Code Subsection 2C The Well Abandonment Report must be submitted to the Catawba County Environmental Health within 30 days upor completion of a well abandonment. Well contractor must schedule well abandonment inspection with Catawba County Environmental Health. WELL TYPE Bored Robbie Phelps 05/25/2016 ISSUED BY PERMIT ISSUANCE DATE chpcnnit 05/25/2016 10:24 Page I of 2