HomeMy WebLinkAboutWELL-04-2018-098533.TIF CATAWBA COUNTY Case N _
:3- eat z Public Health Department Subdivision BLACKBURN RIDGE PH 2
11lr 't .-I Environmemal Health Division FINN 361702567565
^I4 Y PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 LOT4 21
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NAME ON PERMIT: CHRISTINE RYKHUS, 5599 POLSOM LN, IRON STATION NC 28080
Site Address: 3421 SWEETGUM LN, LINCOLNTON NC 28092
Property Size: Square Feet:35,719.20 Acres:0.82
Directions: 3421 Sweetgum Lane, Lincolnton
e,� Owner/Authorized Representative Acknowledgement of Permit Receipt
X/�-- I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
/"'the property described above.
�( JL As the property owner or authorized representative, I have received the above referenced
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permit(s)asrequested in the application for service RBPR-04-2018-28827, by the following method(s):
�/ Received in Person
_ Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
)0(...-- As the property owner or authorized representative I have reviewed and understand the specific conditions
of the permit issued, and further understand that all applicable regulatory requirements specified under the
North Carolina Laws and Rules for Sewage Treatment and Disposal Systems (ISA NCAC ISA.1900),
and/or Well Construction Standards (ISA NCAC 2C .0100), shall apply to the issuance of this permit and
the construction of the wastewater system and/or water supply well permitted.
Permit Issue Date: 04/20/2018
tc___sOwner/Authorized Representative Signature( I 111111,9
Date 23-1 4
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/Time
Method: Fax Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
We wantt tto hear from yoiPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
e110e0011 04/23/2018 10:11
y,A • C:VIAW'BACOUNTY �mtr r lti Caset WELL-04-2018-098533
;i ,ittla y Public Health Department _ d} Subdivision BLACKBURN RIDGE PH 2
G :�.��+ �; Environmental Health Division P: 11':, PINd 361702567565
dt PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 • {ir i' r' LOTH' 21
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Eli ter.
NAME ON PERMIT: CHRISTINE RYKHUS, 5599 POLSOM LN, IRON STATION NC 28080
Site Address: 3421 SWEETGUM LN, LINCOLNTON NC 28092
Property Size: Square Feet:35,719.20 Acres:0.82
Directions: 3421 Sweetgum Lane, Lincolnton
WELL PERMIT
WATER SUPPLY: Individual Well
SETBACKS:
1. BUILDNG FOUNDATIONS 25 FT.
2. EXISTING & PROPOSED SEPTIC SYSTEMS MIN. 50 FT.
3. EXISTING & PROPOSED SEPTIC REPAIR AREA MIN. 50 FT.
4. SEWAGE PUMP SUPPLY LINE 50 FT.
5. UNDERGROUND STORAGE TANKS 100 FT.
6. STREAMS/BROOKS/CREEKS 50 FT.
7. LAKES/PONDS RESERVOIRS 50 FT.
ALL OTHER POSSIBLE SOURCES OF GROUND WATER CONTAMINATION 100 FT.
The well driller must verify all setbacks before drilling the well.
if the well driller is unable to maintain any of the above setbacks,
contact Catawba County Environmental Health at(828)465-8270
before drilling the bell.
Grouting Depth: Minimum 20 Feet
Casing Height: 12" Above Land Surface
All newly constructed private drinking water wells are required to be sampled in accordance with the North
Carolina Rules Regarding Private drinking Water Well Testing(15A NCAC I8A.3800). The fee for this
sampling is included in the cost of the well permit. It is the applicant or property owners responsibility to
notify Environmental Health when the well is ready for sampling.
Water samples will be drawn from an outside faucet unless otherwise specified. Please note that all water samples ale
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 Catawba County Environmental Health at(828)465-8270.
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elf
04/20/2018
AUTHORIZED STATE AGENT APPROVAL DA'Z'E
Permit Expiration Date: 3/12/2023
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Copyright 2014 Catawba County NC
I . 04/192018
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