HomeMy WebLinkAboutEHPR-11-11-13496.TIFL I'' ~ a
s CAWBA COUNTY HEALTH DEPARTMENT ~~L~~~~r ~°~ ~~`~
Tele hone: (828) 46 -82 0 TDD: (828) 465-8200 /' N °_ 9 2 3 1
IP~_AC ~tppr Prm~/~~Opr. r Sysw7T pe - ell Prmt. Replacement Well Well Rpr. Prmt.
Owner/Agent Cd~~ A Phone
Address - ;~ Subdivision ,$~~t~, :;(,~ ,OLp
~G ~ t Section/Block/Phase Lot# 3~
Lot Size D' ections:
Property Address > ,~ ~ /~S
Facility: House Mobile Home Business Multi-family .Other: Pin Number ~~~ '- • (~'
Other .Zoning Approval #
# Bedrooms # Seats # Employees .Application Rate, L/~' GPD Flow ~~
Hot Tub or Spa ye /no p ial Fixtures Basement yes o .100% Repair Area yes/no /'
Basement Plumbing o Water Supply: Private Well Public Semi-Public
Type of System: Trench Bed Pump Pump/Panel Panel LPP Other
r~ r/
Septic Tank Size ~ ~~ ~. Pump Tank Size Nitrification Field: Total Square Feet Depth of Stone /
Bed Size ~ L~ Trench Width Total Length of All Trenches Number of Trenches
Trench Length /1/ // Feet on Center Maximum Trench Depth • ~t Distance of Nearest Well
*DO NOT INSTAL>i, SL'PTIC ~~jF-lir,i~ ~,~1FT* *WELI, RIJCORD REQUIRED AT COI~II'LFTION*
Topo % Slope
Texture
Structure
Clay Min.
Soil Wetness
Soil Depth '
Restric. Hoz. at "
Available space yes/no
Overall Class S PS U
Comments:
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Filter Required ~
Riser required when ~ 1 9 I
tank is more than 6 ~ I
inches deep.
**NO GUARANTEE OR WARRANTY IS IMPLIED OR GIVEN AS TO THE PERFORMANCE OR LENGTH OF TIME THIS SYSTEM WILL
FUNCTION**
*Improaement Permit has no expiration date and is transferable, but may be revoked if site plans or intended use changes for the proposed
facility. An Authorization to Construct is valid for (5) five years from date issued and is not transferable. Well Permit valid for 5 years
provided site conditions do not change. Well location, installation, and protection must meet state and local regulations, and must be inspected
and approved by a representative of the Catawba County Health Department before any portion of the installation is put into use. The siting of
the well by the Health Department staff is to provide protection from known possibl sources of contamination. No volume of water '
guaranteed at any site by t e He Ith Department. ~,~
Permit Date ®' S~ p/f~ ~!~ l EHS ' Y'1 -
Ow r/ t Septic Tank In e B ~ `"~~~ ~ Da e ~~~ ' ~ ~~~
EH .. ~.. Well Installed By Well Grout Approval Date
Well H ~J prov 1 ', Date Sample Collected
Date of es~ilts Results EHS
White -Office Blue -Building Inspection Operation Permit Yellow -Owner/Agent Green -Building Inspection Authorization to Construct