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Home My WebLink AboutSAM-09-2016-076456.TIF CAIIA\ \ p Environmental Health - Division of Public Health COUNTY _, PO Box 389—100-A South West Blvd.-Newton, North Carolina 28658 .a * .� i` r. (828)465-8270—Fax(828)465-8276 morin 2 roilna w.ww.eato-awbacountvnc.)ov/env ironmentalhealth/ AUTHORIZATION OF REFUND Date: 9/7/2016 Case #: SAM-09-2016-076456 Applicant: Lynne Nelson Refund Amount: 5114 Refund Reason: Advised State will be sampling well. Inorganic no longer needed Authorizing Signature: MPJ�l/I e-4Received By Staff: Perk C7 Date: in it&o ,� "Leading the Gray to a Healthie, Community" E M SN „ ,m� Public Health t g CatawbagGounty'North Car}oIinwthD l ursemntEY°cher i ' ,_,,s-Kiii$ ak?'.ts+ . u..5�s..;. tnea . »» _..s..:r Vendor No. Date 09107116 Make Payment To: �4'A COG Voucher No(s). Lynne Nelson Ee t a . POBox3 v Tor . ; Terrell, NC 28682 842 ATTACHMENT Prepared by Julia English Description Amount Advised State will be sampling well. Inorganic no longer needed 114.00 Sub-Total $ 114.00 Food Tax Sales Tax Total $ 114.071 Ir a�, �§ 1413 .i der »'�, t ;�T„`�I`4-0n` imp�ma C 9 Ti x c a t5';a B,f r p �-sr°r 9 n.:°» s U '' vi t5 ; �� ° (-Y a4 i i `r it x�k&'3t t f � au SSA ya s ign ,,i N i3 w -k Uf4.44.4, T s F�,undN j Cost,C,enter, .,, Object Project°;, ?d�Amount�„a :591-411,0 11i580200 663000.=.� Total - The undersigned hereby certifies that the goods or services specified above have been received or performed. Payment has not been previously authorized and this expenditure is a proper charge to the appropriation indicated. The above charge is certified to you for payment. (SIGNATURE-APPROPRIATE OFFICIAL) r Cp CATAWBA COUNTY 100A SOUTHWEST BLVD {p H NEWTON, NORTH CAROLINA 28658 RECEIPT '.< K �isA¢ PHONE: 828.465.8399 kw�sv% C Thursday, September 15, 2016 8142 SA1 www.catawbacountync.gov PAYOR: Nelson, Brian & Lynne PAYMENTS TRANSACTION NUMBER: TRC-835361-15-09-2016 PAYMENT DATE : 09/15/2016 PAYMENT TYPE: DV INVOICE NUMBER FEE NAME FEE AMOUNT 09-16-332324 Inorganic Chemical Sample Fee ($114.00) TOTAL PAYMENTS : ($114.00) SAM-09-2016-076456 CASE TYPE: Water Sample WORK CLASS: Inorganic Chemical SITE ADDRESS: 3604 SLANTING BRIDGE RD, SHERRILLS FORD NC 28673 Applicant BRIAN & LYNNE NELSON, PO BOX 3, TERRELL NC 28682 H:8284782408C:828-308-1422 **NO PEOPLESOFT ACCOUNT ASSIGNED ** receipt 09/15/2016 16:05 Page 1 of 1 K31A C i Case p SAM-09-2016-076456 4 G./. CATAWBA COUNTY HEALTH DEPARTMENT < refit ii r, Environmental Health Section L %� V4b �c /8 4'1 sm 09/02/2016 WATER SAMPLE APPLICATION Applicant BRIAN& LYNNE NELSON, PO BOX 3, TERRELL NC 28682 H:8284782408C:828-308-1422 Site Address: 3604 SLANTING BRIDGE RD, SHERRILLS FORD NC SELECTED SAMPLES 28673 Inorganic Name of Subdivision: Parcel Number: 461701079593 Lot: Block: Specific Directions Description: Inorganic Only* *The actual well is located in the back of the home under the concrete slab adjacent to the heat pump. Reason for Sample:curious about quality of water Type of Well "iiI' ,ik:�; ' Drilledl,Ei ffit= Is the well on this same property? I1IIfERYesM Is outside spigot available to collect sample? ;%115e091 Is power on? MEN s'IA Has well been tested before? 11 t'I' ' Results Does the plumbing come out the top of the well through a sanitary, well seal? PWnes Does the well ever become cloudy or has there ever been a problem with taste and/or odor? ,t(ilNo...MN Explain Does the well top extend twelve (12) inches above the ground or well slab? EUrnk"riowa The well is in: ET t, .. Rearl IIM'Ijl r Does this well supply water to more than one home? 1;:iii:,g1MIThl 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. Date C)17 147 Signature or Owner or Agent _1 i " r It ' Area 1 grflDSCIPT10N1gi ,-;ifi ry �" .k ' "0DTE � lFEF1 I Il4C L: :641C (, . • vL � AMONT n Inorganic Chemical Sample Fee 09/02/2016 $114.00 t fi� I�s1'�iii ITOTALITE.0 llIil' IIIIII Yl l��t 911.T '�:IiIIIIIII1t'l i11I1�ib d 'I�!$11A4'00 v� III ' I ISI 1 I��Illil��I} '. 7t l t R!i 1111 �i1 Lm I ,�i ii a I t ; ti �Ii IIUIHI��Ii e JC i„IWilW41tl6�1UW.L.,.. � tSGao:.. •"irtflfhldVl.9t":'�s ii7111d -iU lUn � exp} rsamapplication 9/2/2016 Page 1 of 2 k .1isPrint Form C A 1. [ \ \ I. 1Nor \ Catawba County Public Health { - — COUNTY ._ www.catawbacountync.govienvironmentalhealth Environmental Health ` ' NprthCarolina P.O. Box 389, 100-A South West Blvd., Newton, NC 28658 Phone (828) 465-8270. Fax (828) 465-8276 !µ1 Water Sample Application q �} 'J U/� Sample Requested By B nun and Ilrine. IV e-IS.r�On Home Phone 0 20 -L 7 8G 2 LID Property Address 3 to b4 Sian* n/d IF�c t�3e Rd. Business Phone g 22 3 00 - p O { I Mailing Address 20 \ VJ C�X 3 , 1F (Lf e`1, NC_ 2g(0 8 2 Driving DirectiansONtQ 1'I VJav I (0 ` C)Ol.l-r\ OTake I--\ w v ISO e aS`- n Oe ec I } p l Last dcievJay en �JUrn \ e� fi 0,-4- RDFS R0 S��Q do 40 51a„�;n3 e,ate - r\c k 1,e-Sore Aec5eci; J / ,n Sample Requested: Bacteriological Inorganic Chemical / Eleat_ _ _ pF Stierr;ll: 1 11 Fora ea. Sample reason: CUrIOUS n\po ctual�\-J o Wale( Type of Well: Drilled 1/ Bored Dug Other • Is the well on this same property? Yes V7 No Is outside spigot available to collect sample? Yes ✓ No Is power on? Yes ✓ No Has well been tested before? Yes No l/ Unknown Results Does the plumbing come out the top of the well through a sanitary well seal? Yes ✓No Unknown Does the water ever become cloudy or has there ever been a problem with taste or odor? Yes No 1,7-- Explain /Explain Does the well top extend 412 inches above the ground or well slab? Yes No Unknown The well is located in front rear {/ left side right side l of the house. Does well supply water to more than one home? Un def C On C Ce 1 C, Yes No i__„-------- S 1:1\.0 _„--------5a\c adscaceni --Vo (x� `/ j_ lit a+ p u m t ► Date v-2 7-) (0 Signature of Owner or Agent ► _ IL . ' AL! _/ 1 / RECEIVED "LeSE157,11uniSty to a Healthier Community" QD o. ....v ' UUOHealth ENVIRONhEN � aIf CA � GOU 4'A CATAWBA COUNTY O�� 100A SOUTHWEST BLVD nNEWTON, NORTH CAROLINA 28658 RECEIPT am, y, <►e PHONE: 828.465.8399 l'1:41 a®v/ �C Friday, September 2, 2016 1842 sM www.catawbacountync.gov PAYOR: Nelson, Brian& Lynne PAYMENTS TRANSACTION NUMBER: TRC-813768-02-09-2016 PAYMENT DATE : 09/02/2016 PAYMENT TYPE: Check 6197 Received by mail INVOICE NUMBER FEE NAME FEE AMOUNT 09-16-332324 Inorganic Chemical Sample Fee $114.00 TOTAL PAYMENTS : 5114.00 SAM-09-2016-076456 CASE TYPE: Water Sample WORK CLASS: Inorganic Chemical SITE ADDRESS: 3604 SLANTING BRIDGE RD, SHERRILLS FORD NC 28673 Applicant BRIAN & LYNNE NELSON, PO BOX 3, TERRELL NC 28682 H:8284782408C:828-308-1422 **NO PEOPLESOFT ACCOUNT ASSIGNED ** receipt 09/02/2016 15:22 Page 1 of 1