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. CATAWBA COUNTY'HEALTH DEPARTMENT
• 1 elep one: (828) 465 -8270 TDD: (828) 465 -8200 W LS # .200 / - t)) 30 / _
IP AC ?c Rpr. Print. ,O pr. Print.\ Sys. Type 3B /(Wrell Print. X Replacement Well Well Rpr. Print._ -
Ovener /Agent g /GO 4 ii. s.19 /4.frriwr Phone I OS/ - C2R' - 4l2'ich,Q.
Address /4 416 cAt.ria..Dn41 R.64,0 Subdivision Lt /J1 .mcvt) RItD6
• • �. - I. _ Section/Block/Phase _ Lot(
Lot Size /.? A s Directions: _ S phi.e.C c 02/JA-.0 (4 ennt1 i J . fS 46/364/1 1A11/4"' R..0411
A2_RGF O•n (Z) DZSt . (e 6 12D.S, O ' • y. 4 .rIDMS eaaz S7 esur..,T n �/ • , • , Li
' . - �. 4 _ ■ . . Property Address II G �, , 6 • It/ 6 • _
Facility: House x Mobile Home Business Multi -fans y . Other: Pin Number 96 1? f)/ l 96 •
Other . Zoning Approval #
# Bedrooms 9' # Seats // Employees . Application Rate . `!t GPD Flow VIM
Hot Tub or Spa ye ..pecial Fixtures Basemen t o o . 100% Repair Area yes /no
Basement Plumbing trfl o Water Supp y: Private Well Public Semi - Public
Type of System: Trench X Bed -- Pump x Pump /Panel -- Panel —LPP — Other
Septic Tank Size /0 0 6 Pump Tank Size /000 Nitrification Field: Total Square Feet Jot() d Depth of Stone / A "
Bed Size Trench Width 3 ' Total Length of All Trenches yo a Number of Trenches
Trench Length /o o /tfeo / / a0/ /00 / — 1— Feet on Center ? ' Maximum Trench Depth A4' i v. Distance of Nearest Well Sa '4.
*DO NOT INSTALL SEPTIC WHEN WET* *WEL1. RECORD REQUIRED AT COMPLETION*
* * ** ** ****** * * *** ** * ** ** ************. t, y�, y*********************************************** * * * * * * ** * ** * * *** * ** * * * * *** * * * **
Topo % Slope ��CC
Texture
Structure Pu 1.8 p . P?f ,s ,s,„„ r ill N Al ( FJ (, v & Z
Clay Min.
Soil Wetness To 43 Ae r e wet) X7 - /n)
Soil Depth
Restric. Hoz. at
Available space yes/ i.
w \ Q •se rim.< co/okno-reyt, 74 cazi._
Overall Class S PS *r` ., \ N'IsAta
Comments: ` -,--
� SE "E (. P A+ys ac �4f s� , i c�..
See ..5 No \ti \
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3 1.1. 1 I it c P er ." ,.a . — �
Filter Required r
Riser required when / i / ni I
tank is more than 6 ! t / / / t I J I
inches deep. / / / / - ,
* *NO GUARAN . tt R � • ' • NTY IS 1MPLIE IVEN A.'. • 4" l ORMANCE OR LENGTH OF TIME THIS SYSTEM
WILL FUNCTION** � **** * * * ** ** * * * * * * * ** ** * * * *' ** ** * * * * ** v . k+******************************* * ** * * * * * * * * * * * * * ** * * * * * * * * ** * **
*Improvement Permit has no expiration date and is trait ierahle. but may be revoked if site plans or intended use changes for the proposed
facility. An Authorization to Construct is valid for (Si five years from date issued and is not transferable. Well Permit valid for 5 years
pros ided site conditions do not change. Well location, installation, and protection must meet state and heal 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 possible sources of contamination. No volume of
s % ater is guaranteed at any site b the Health Department. /'
Permit Date q4 G .,4•7"" / Od 1 r EHS 6- S — - £ S.
Owner /Agent — . - • .411111.� Septic Tank Installed By • � - r 'T9 2D4.il f Date S' - //- 0 2
EHS �- or . pt Ins . B i4 c A w mac_ �.,, Well Grout Approval Date 3 - 0 2
Well Head Approval Date - .Z y - n Z Date . It .le Collected -
Date of Results Results EHS
White Office Blue - Budding Inspection Operation Permit Yellow - Owner: Agent Green - Building Inspection Authorization to Constntct