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Home My WebLink AboutSAM-09-2016-076537.TIF 4iA C0 Case# SAM-09-2016-076537 ,;u t $ G j '14_, CATAWBA COUNTY HEALTH DEPARTMENT L vv`` Environmental Health Section /8 41y 09/07/2016 WATER SAMPLE APPLICATION Applicant DEBORAH BONELLI,4445 SLANTING BRIDGE RD, SHERRILLS FORD NC 28673 C:8284781050 Site Address: 4445 SLANTING BRIDGE RD, SHERRILLS FORD NC SELECTED SAMPLES 28673 Bacterial Name of Subdivision: Inorganic Parcel Number: 460602891310 Lot: 41 Block: Specific Directions Description: Inorganic & Bacteriological Reason for Sample:Water tastes bad Type of Well 's°y''.,DilinerdAlirliME Is the well on this same property? EgrainEll Is outside spigot available to collect sample? Yes''`'t Is power on? EilliuJ;,uYeSI fF I Has well been tested before? lib Ir Yes'111"' Results NeiBiatiriennEllretel,t iltisi 7-: Does the plumbing come out the top of the well through a sanitary well seal? °'Unknown Does the well ever become cloudy or has there ever been a problemr� with taste and/or odor? »r '�NYeslr7if�: Explain unableuto,da II)ehaste'1if[ti... 1ililil .iiw�lli l t nt;Y: J 1111 .ink ry I 1 k7:'. o1{ 'INS' ; , 1�H�r Does the well top extend twelve (12) inches above the ground or well slab? FTTATIII71 The well is in: An ir RearAI(wig ..,:t041 Does this well supply water to more than one home? EI; giyims',"I" I 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 S.o��C- UCJ, y�IPJ�I IR( '" 1 d Q l� Signature or Owner or Agent Area 1 1FEED ES RIP ION° i ', IF"�Ililryir!= 1 ir1�^lr t9I DATE I `��!IJFEE A!MOUNTdl ii Bacteriological Sample Fee 09/07/2016 $58.00 Inorganic Chemical Sample Fee 09/07/2016 $114.00 ' Ib 17+ 'TOTAL FEESI, ? :,illlhlhlih, li 1 j"ti 172 OO I;t ` �'t�� 1,h I � �IIII'I III � g 1 �, ll... 'll�� ✓!i � 'nSUIW`e"' :::; kIigr..0 uthii 4. alkili..Id L'' - �uu'I Iu In�JWt aiwai.::W u, r' rsamapplication 9/7/2016 Page 1 of 2 cJ\ J1j int Catawba County Public Health COUNTY - www.catawbacountync.gov/environmentalhealth ' ;. � . Environmental Health North Caroliner P.O. Box 389, 100-A South West Blvd., Newton, NC 28658 Phone (828) 465-8270. Fax (828) 465-8276 �nLWater Sample\ � Application ( 1 J� Sample Requested By 1 (n\ 1 J`�-�(5 N e.:0,-� I-2. Home Phone g a 3 `I 2 1 v S C Property Address \A\-\\-"\C 1 5 lA\Ul�� 2 kacke ' \� Business Phone Mailing Address (✓��n-Q_v'Y'YAl S fU '�'t /� C d 3 Cp 3 Driving Directions � 1011V5\NEs To L S lJ Sample Requested: Bacteriological Inorganic Chemical*Other Sample reason: ‘\I / Type of Well: Drilled C�. Bored Dug Other Is the well on this same property? Yes No Is outside spigot available to collect sample? Yes No Is power on? Yes No Has well been tested before? Yes r\ No Unknown Results l- 00 CI 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 Explain N Does the well top extend 12 inches above the ground or well slab? Yes No Unknown The well is located in front rear left side right side NI. of the house. Does well supply water to more than one home? Yes No r Date �J ` \ - I '1Q Signature of Owner or Agent ...L11 _ Saiii„,s___ "Leading the Way to a Healthier Community" ZPubUUc ; F6cD F Iso; co CATAWBA COUNTY 5 ft!}a 100A SOUTHWEST BLVD Q NEWTON,NORTH CAROLINA 28658 RECEIPT U MArarcwinw:T G rip PHONE: 828.465.8399 was Wednesday, September 7, 2016 1842 SM www.catawbacountync.gov PAYOR: Bonelli, Deborah PAYMENTS TRANSACTION NUMBER: TRC-820860-07-09-2016 PAYMENT DATE : 09/07/2016 PAYMENT TYPE: Credit Card INVOICE NUMBER FEE NAME FEE AMOUNT 09-16-332392 Bacteriological Sample Fee $58.00 09=16-332392 !I iu ::Tr?i ��u! o',bInorganicl.Chemical Sample'Feet, I Ia.r'" w' ;d$1'!1'4"001 TOTAL PAYMENTS : $172.00 SAM-09-2016-076537 CASE TYPE. Water Sample WORK CLASS: Multiple Different Samples SITE ADDRESS: 4445 SLANTING BRIDGE RD, SHERRILLS FORD NC 28673 Applicant DEBORAH BONELLI,4445 SLANTING BRIDGE RD, SHERRILLS FORD NC 28673 C:8284781050 ** NO PEOPLESOFT ACCOUNT ASSIGNED ** receipt 09/07/2016 09:26 Page 1 of 1