HomeMy WebLinkAboutWELL-06-2016-073108.TIF �9 \ CATAWBA COUNTY Case# -
ii Gf . Public Health Department Subdivision
' o•• H Environmental Health Division PIN# 367604925649
\ +� PO;3os 389, 100-A Southwest Blvd.Newton.NC 28658 LOT# 1
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NAME ON PERMIT: JEFFREY & ASHLEY HARTSOE, 222 BRENTWOOD DR, MAIDEN NC 28650
Site Address: 4955 LEBANON RD, MAIDEN NC 28650
Property Size: Square Feet:67,082.40 Acres:1.54
Directions: Hwy 16 turn right on Hwy 150, turn right on Lebanon, lot on left
Owner/Authorized Representative Acknowledgement of Permit Receipt
ft.] certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
property described above.
v 7.I-. As the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service RBPR-05-2016-23901 by the following method(s):
'Received in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
---( IL. 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: 06/06/2016 l Owner/Authorized Representative Signature �� �f�7
Date 6- 6 `76
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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ehpemit 06/06/2016 11:56 Page 4 of 4
Case#
■I3A � CATAWBA COUNTY 0• 0• � - � WELL-06-2016-073108
�� r] G4 Public Health Department c r I� • Subdivision
< ; ,�1. K Environmental I-lealth Division , • ,o r n PIN# 367604925649•
46> PO Bos 389. 100-A Southwest Blvd,Newton,NC 28658 LO"f# 1
Ig.2 s. •--0� — - A
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NAME ON PERMIT: JEFFREY & ASHLEY HARTSOE, 222 BRENTWOOD DR, MAIDEN NC 28650
Site Address: 4955 LEBANON RD, MAIDEN NC 28650
Property Size: Square Feet:67,082.40 Acres:1.54
Directions: Hwy 16 turn right on Hwy 150, turn right on Lebanon, lot 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.
9 . 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 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.
Jason Boyd 06/06/2016
AUTHORIZED STATE AGENT APPROVAL DATE
ehpemiit 06/06/2016 11:57 Page 1 of 3
`�13� Permit # RBPR 5-16.23901
CATAWBACOUNTY Name Jeffrey and AshleyHartsoe
'� 7 Public meat l Health Di Address 4955 Lebanon Rd Maiden NC
�,°°`"I�s'7 Environmental Health Division - PIN# 3676049263 77
„d�.. PO Box 389, 100A Southwest Blvd, Newton NC 28658
I 1842 m (828)465-8270 Fax (828)465-8276 'MD(828)465.8200
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