HomeMy WebLinkAboutSAM-09-2016-976862.TIF SBA C Case u SAM-09-2016-076862
H5: $ G,z CATAWBA COUNTY HEALTH DEPARTMENT
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171 ''C Environmental Health Section
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09n5/2016
WATER SAMPLE APPLICATION
Applicant WAYNE CRATTY, 264 28TH AVENUE PL NE, HICKORY NC 28601-1120
H:8283289818C:8282445173
Site Address: 264 28TH AVE PL NE, HICKORY NC 28601 SELECTED SAMPLES
Bacterial
Name of Subdivision:
Parcel Number: 371413020869 Lot: 17 & PT 18 Block:
Specific Directions
Description: Bacteriological Only*
Please call before taking the sample.*
Reason for Sample:Wife Wants Water Tested
Type of Well Mr 1 f lDrilted`.--4+1111 Is the well on this same property? l .'Yes`
Is outside spigot available to collect sample? 'v"'$;,Yes tilla Is power on? RN,Yes=
Has well been tested before? 111glH1'.Yes1I'1�''J Results Noiissue's9'- J i�REIMIIMORM,1 I111116 11I1, ;1�
Does the plumbing come out the top of the well through a sanitary well seal? r'-0 1 Ye_s hip
ll
Does the well ever become cloudy or has there ever been a problem with taste and/or odor? jfINo�I
Explain
Does the well top extend twelve(12) inches above the ground or well slab? ILITI noNin-
G.:, m'"
The well is in: ' Rear Ih '°;hl,,I,...:
Does this well supply water to more than one home? LITEFIMII
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, 1111
please contact Cat. ba County Environmental Health at(828)465-8270.
Date A ` Signature or Owner or Agent ane
de
Area 2 p
�RFEE[DESCRIPTION"• . 1i004u.:117•1117.1111,4•,,:•1ii'IllJDATE ,P ' „'1Jrllii 1FEE�AMOUNT%
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Bacteriological Sample Fee 09/15/2016 $58.00
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rsamapplication 9/15/2016 Page 1 of 2
cALrrA\ �'� 4�u Catawba County Public Health
COUNTY
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� .. - . www.catawbacountync.
gov/environmentalhealth
� Environmental Health�kigi 't � North C.rolknn_
P.O. Box 389, 100-A South West Blvd., Newton,NC 28658
Phone (828) 465-8270. Fax (828) 465-8276
Water Sample Application
Sample Requested By ;11/,yyf- 6.1.-&77-97 Home Phone g,el- .77/2" 26/F
Property Address 26",Z-.7g/ Air /1717Z- �� ��� Business Phone
Mailing Address 26 - 'OS'�'��i / 4 2 ' �±
Driving Directions 29 T ✓7-r /7t �i2/Z>Z7 ✓fes/fX—
/e i OA/ �jc 4477 6c9 °A/ /G�j-'7
Sample Requested:f BBaacteriological ✓ Inorganic Chemical Other
V i'�
Sample reason: f� W✓A/7 -f pern hoz-7,7
Type of Well: Drilled 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 V No Unknown Results
Does the plumbing come out the top of the well through a sanitary well seal? Yes V No Unknown
Does the water ever becomec/ cloudy or has there ever been a problem with taste or odor? Yes No
Explain �l"e,77e
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 of the house.
Does well supply water to more than one home? Yes No
c#776c Date / Signature of Owner or Agent / e
1
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"Leading the Way to a Healthier Community"
P blic
° t _ f x.'Health ,
C CATAWBA COUNTY
100A SOUTHWEST BLVD
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NEWTON, NORTH CAROLINA 28658 RECEIPT
" "p°� mV►a ! PHONE: 828.465.8399
Asa; Thursday, September 15, 2016
1842 se+ www.catawbacountync.gov
PAYOR:
Crafty, Wayne
PAYMENTS
TRANSACTION NUMBER: TRC-834305-15-09-2016
PAYMENT DATE : 09/15/2016
PAYMENT TYPE: Credit Card
INVOICE NUMBER FEE NAME FEE AMOUNT
09-16-332702 Bacteriological Sample Fee $58.00
TOTAL PAYMENTS : $58.00
SAM-09-2016-076862
CASE TYPE: Water Sample WORK CLASS: Bacterial
SITE ADDRESS: 264 28TH AVE PL NE, HICKORY NC 28601
Applicant WAYNE CRATTY, 264 28TH AVENUE PL NE, HICKORY NC 28601-1120
H:82832898 I 8C:8282445173
**NO PEOPLESOFT ACCOUNT ASSIGNED **
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receipt 09/15/2016 10:27 Page 1 of 1