HomeMy WebLinkAboutWELL-06-2016-073314.TIF ,...•?,' . CATAWBA COUNTY Case# WELL-06-2016-073314
al 2 Public Health Department Subdivision CRESCENT LAND AND TIt
4 ; -ia K Environmental Health Division
PIN# 461601279569
!may 2 ,M PO Box 389, 100-A Southwest Blvd, Newton,NC 28658 LOT# 73
NAME ON PE,MIT: JERRY STONE, 8316 NOLLEY LN, SHERRILLS FORD NC 28673
Site Address: 8316 NOLLEY LN, SHERRILLS FORD NC 28673
Property Size: Square Feet:55,321.20 Acres:1.27
Directions: East on Hwy 150, Right on Slanting Bridge Rd, Left on Drena Dr, Right on Giles Ave, Left onto Nolley Lane,
5th house on Left.
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-06-2016-24031 by the following method(s):
Received in Person
Eacsimile Transmittal (Return form with signature required)
lectronic Image Transmittal/E-mail (Return receipt required)
•
-)c _ 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: 06/10/2016
Owner/Authorized Representative Signature
Date
Documentation of Permit(s) Transmittal
(permit transmitted by e ectronic or other means)
Permit trans itted b (i it II 1 II h (name of person s. ndin. permit)
Signature tart�L�1 .lcu •. ._� :-i%1 Date/Time I . 0 0 J 0�O
Method: Fax \Xmail US Mail Other
Owne 's request to send by the above indicated method of transmittal in lieu of signature
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dime mit 06/10/2016 08:17 Page 3 of 3
CATAWBA COUNTY 0 I o 1. . 0 Case# WELL-06-2016-073314
n'y\ Public Health Department }n � Subdivision CRESCENT LAND AND TII■a.
?**** ; ', Environmental Health Division 1t4 ,� 'r PIN# 461601279569
'" /% PO Box 389. 100-A Southwest Blvd,Newton.NC 28658 ELI ° ° LOT# 73
rag/ :� -I
•Ci IABO . °
NAME ON PERMIT: JERRY STONE, 8316 NOLLEY LN, SHERRILLS FORD NC 28673
Site Address: 8316 NOLLEY LN, SHERRILLS FORD NC 28673
Property Size: Square Feet: 55,321.20 Acres:1.27
Directions: East on Hwy 150, Right on Slanting Bridge Rd, Left on Drena Dr, Right on Giles Ave, Left onto Nolley Lane,
5th house 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 (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 06/10/2016
AUTHORIZED STATE AGENT APPROVAL DATE
clrpennit 06/10/2016 08:17 Page I of3
y1-A1 Permit# EHPR-6-16-23848
CATAWBA COUNTY Name
Jerry Stone
4� ' ��2 Public Health Department ry
d "�"?:�i�'�J Environmental Health Division Address 8316 Nolley Lane Sherrills Ford
%at r PO Box 389, 100A Southwest Blvd, Newton NC 28658 NC
1$42 sM (828)465-8270 Fax (828)465-8276 TDD(828)465-8200 PIN# 461601279569
Site Plan Well Permit
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