HomeMy WebLinkAboutEHPR-08-2015-22128 (2).TIF~j;`\\ CATA_~.'BA COUNTY ~
~' L~S Case # WLS2008-00941
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~ t ~blic Health De artment
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Subdivision
~ Environmental Health Division ~ ~ rat,.. `
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CRESCENT LAND AND TIME
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PO Box 389, 100-A Southwest Blvd, Ne\vton, NC 28658 jv ] 14
IH4// (828j 46~-8270 FAX (828) 46~ 8276 TDD (828) 46~-8200 1 • (C t~ ~l ~ I ~ P1N#
~/" 4607 1 5 644 1 9 1
Applicant /Owner: MICHAEL BROOME
. W n~St~9 SC
Site Address: 3943 CHEVLOT HILLS RD SHERRILLS FORD NC //
Property size: SF .75 ACRES /
Directions: 16S/ 150E/ LEFT CHEVLOT HILLS RD/ ON RIGHT BEIGE BLOCK HOUSE (HOUSE IN PART OF ROAD THAT
IS IN CIRCLE)
WELL PERMIT
Proposed Use: Private ~ Public Semi-Public Other
GROUTING DEPTH: MINIMUM 20 FEET
SETBACKS: `.
I. BUILDNG FOUNDATIONS 25 FT. 5. UNDERGROUND STORAGE TANKS 100 FI'.
2. EXISTING & PROPOSED SEPTIC SYSTEMS -MIN: SO FT. 6. STREAMS/BROOKS/CREEKS 50 FT.
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3 EXISTING & PROPOSED SEPTIC REPAIR AREA -MIN. ~0 FT. 7. LAKES/PONDS RESERVOIRS 50 FI
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4. SEWAGE PUMP SUPPLY LINE 50 FT.
ALL O`I'LIER POSSIBLE SOURCES OF GROUND 'L'ATER CONTAMINATION 100 FT.
The well driller must verify all sepearations are adhered to before drilling the well.
If the well driller is unable to maintain any of the above separations, contact the Health Department at (828) 465-8270 before drilling the well.
SEE ITE PLAN FOR P RMI TED WELL LOCATION
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Iss d By Permit Issuance Date
Customer
G
Date
WELL INSPECTION:
GROUTED DEPTH: 20' l~ DATE: ~ ~ ~ ~ INITIALS: Yh
APPROVED CASING: PVC _,L STEEL DATE: INITIALS: ~'lim
CASING FIEIGHT 12" ABOVE LAND SURFACE DATE: Z 0 INITIALS: _~yy1~~1//ti
WELL COMPLETION REPORT RE EIVED DATE: I ( INITIALS: ~1T
WELL HEAD APPROVED ~ DATE: ~ Z o Dg INITIALS: p-[! l'h
WATER SAMPT,FS TAKRN• RA 1/ Ifs r/ N/N l/ T~ATF~ 12I ~e IDg
Well Driller
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D~ to D filled
Well permits are valid for 5 years from the date of issuance and are subject to suspension and/or revocation fro non-compliance with
appropriate state and local rules and regulations, or if false information was-given in order to obtain a permit. Wells shall be constructed
in accordance with all state and local regulations and rules. The Well Completion Report must be submitted to the Health Department
within 30 days upon completion of a well.
CERTIFICATE OF COMPLETION
Autho i ed State Agent
2 36 0 `~
Approv Date
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uhf CATA~'BA CCIUNTY Case # WLS2008-00941
U Public Health Department
'T ~_- /~ ' Subdivision
~ Environmental Health Division CRESCENT LAND AND TIME
~~ :`- ~' SecdBL/Ph/Lot #
PO Box 389, 100-A Southwest Blvd, Newton, NC 28658 114
IN_g2 sa (828) 465-8270 FAX (828) 46~-8276 TDD (828) 465-8200 PIN#
460715644191
Applicant/Owner MICHAEL BROOME
Site Address: 3943 CHEVLOT HILLS RD SHERRILLS FORD NC
Property Size: SF .?5 ACRES
Directions: 16S/ 150E/ LEFT CHEVLOT HILLS RD/ ON RIGHT BEIGE BLOCK HOUSE (HOUSE IN PART OF ROAD
THAT IS IN CIRCLE)
Improvement Permit ~ Authorization To Construct
SITE PLAN
® Well Permit ph ~y
System components represent approximate contours only. The contractor must flag the system prior to beginning the
installation to ensure that proper grade is maintained. Do not install system under wet conditions. This permit is subject of
re cation if the 'te nor si conditions are altered.
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Auth r zed State Agent Date Form C
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