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Home My WebLink AboutSAM-09-2016-076803.TIF A co Case is SAM-09-2016-076803 F MI6 " CATAWBA COUNTY HEALTH DEPARTMENT d' ," � �eF h �v ,�irnir.��eol" � Environmental Health Section ' i�l,;r \842 sM 09/14/2016 WATER SAMPLE APPLICATION Applicant WILLIAM RICE, SR, 6046 LITTLE MOUNTAIN RD, SHERRILLS FORD NC 28673-7832 H:7044835957C:8288523387 Site Address: 6046 LITTLE MOUNTAIN RD, SHERRILLS FORD NC 28673 SELECTED SAMPLES Bacterial Name of Subdivision: Parcel Number: 369701093960 Lot: Block: Specific Directions Description: Bacteriological Only* Reason for Sample:for drinking water Type of Well E J. _,H a Bbleir 57,falffir Is the well on this same property? ! 411i 11 Is outside spigot available to collect sample? Eyes lflBfl Is power on? LlibilipY0411111,i Has well been tested before? illi arnio is Results Does the plumbing come out the top of the well through a sanitary well seal? ",Lyes';° Does the well ever become cloudy or has there ever been a problem with taste and/or odor? FERENcmaiiiii Explain Does the well top extend twelve (12) inches above the ground or well slab? MitYsis, MI The well is in: F i)ib,IT " ,±1Front a in Does this well supply water to more than one home? taaN018itthid 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 contactCaatawba County Environmental Health at(828)465-8270. Date / '7° /Y Signature or Owner or Agent artner Area 1 E F�.dull llll l 111 Jtmh ll(1r r { INRln r i11NTti ll 11'll�ll�p li li i �r (l , ��o i. �, r EEiDESCRIPTION h i {Milk .h�^'� i In'':, ih.�'1tl1�LDATE !I t. ;'!I�EEAMOUNTiI Bacteriological Sample Fee 09/14/2016 $58.00 5'4 1, r' 11OTALElair filfillui,in ,;,:4,>tliiiiii1 -(11if�ii1rri111111S50 IIrik : lWail l'im-ra usmpIDlltiiii il:rUWWIILIWllthiUos. -Mgr' afliFrni1111i - kuGlitiEi i rsamapplication 9/14/2016 Page 1 of 2 cA \ -_,, � � Catawba County Public Health COUNTY www.catawbacountync.gov/environmentalhealth nrZ " ,'y'. --� . Environmental Health North Carolina P.O. Box 389, 100-A South West Blvd., Newton, NC 28658 Phone (828) 465-8270. Fax (828) 465-8276 Water Samp�l/le� Application �/7 C /��%3 C�� Sample Requested By 1 Ai//l : 1 ii CI IM Mn p !// /1 'C �5- -THome Phon� ' D `c/y /Qa 7 G Property Address T� (� IA_ �a ( Business Ph Phone�2 d U cL 7 5 D Mailing Address // !l /7 l 1 Driving Directions 3� S !' h, `e,S a ) v d Chc4 ' ,�frr e�L __/ ((e_ �� ro SS r r�`C�-4-- 3 -RA S� A Sample Requested: Bacteriological (Inorganic ChemicalOther Sample reason: —4t` JiA 1J 'I C ""/01 le7-- Type of Well: Drilled Bored iliv,Dug Other Is the well on this same property? Yes No Is outside spigot available to collect sample? Yes V/ No Is power on? Yes No Has well been tested before? Yes No nknown 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 Explain Does the well top extend 12 inches above the ground or well slab? Yes t/No Unknown The well is located in front V rear left side right side of the house. Does well supply water to more than one home? Yes No // Date / /I 76SignatureofOwnerorAgentN. 72•2/ iiii "Leading the Way to a Healthier Community" c°1 mI- !WfiC UUHealth ` ' rIBA O CATAWBA COUNTY p 100A SOUTHWEST BLVD u NEWTON,NORTH CAROLINA 28658 RECEIPT p ue<�a PHONE: 828.465.8399 U ,,;' v4sv: 1'C Wednesday, September 14, 2016 1842 SM www.catawbacountync.gov PAYOR: RICE, SR, WILLIAM PAYMENTS TRANSACTION NUMBER: TRC-832258-14-09-2016 PAYMENT DATE : 09/14/2016 PAYMENT TYPE: Credit Card INVOICE NUMBER FEE NAME FEE AMOUNT 09-16-332639 Bacteriological Sample Fee $58.00 TOTAL PAYMENTS : 558.00 SAM-09-2016-076803 CASE TYPE: Water Sample WORK CLASS: Bacterial SITE ADDRESS: 6046 LITTLE MOUNTAIN RD, SHERRILLS FORD NC 28673 Applicant WILLIAM RICE, SR, 6046 LITTLE MOUNTAIN RD, SHERRILLS FORD NC 28673-7832 H:7044835957C:8288523387 ** NO PEOPLESOFT ACCOUNT ASSIGNED ** receipt 09/14/2016 08:33 Page 1 of I