HomeMy WebLinkAboutWELL-04-2018-098679.TIF 74 • \ CAJAWLIA couN 'Y Case q WELL-04-2018-098679
.r.1 Public Health Department Subdivision
' — Environmental Health Division PINK 365602553940
y\11411 / PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 LOT/I
NAME ON PERMIT: MICHELLE SHOOK, PO BOX 493, MAIDEN NC 28650
Site Address: 4692 RAINEY LN, MAIDEN NC 28650
Property Size: Square Feet:289,674.00 Acres:6.65
Directions: East Maiden, Right on Rainey Ln, Property on the Left
Owner/Authorized Representative Acknowledgement of Permit Receipt
\/%t• I certify that I am the owner or authorized agent(owner's authorization required) representing the owner of
the property described above.
/ As the property owner or authorized representative, I have received the above referenced
permit(s) ass requested in the application for service 1213PR-03-2018-28645, by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
_ Electronic Image Transmittal/E-mail (Return receipt required)
.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 (I5A NCAC I8A.1900),
and/or Well Construction Standards (I5A 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: 04/24/2018
Owner/Authorized Representative Signature
i
Date 9— ,2 — /8'
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
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NAME ON PERMIT: MICHELLE SHOOK, PO BOX 493, MAIDEN NC 28650
Site Address: 4692 RAINEY LN, MAIDEN NC 28650
Property Size: Square Feet:289,674.00 Acres:6.65
Directions: East Maiden, Right on Rainey Ln, Property on the Left
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 OTIIEI2 POSSIBLE SOURCES OF GROUND WATER CONTAMINATION 100 FT.
The well driller must verily all setbacks before drilling the well.
lithe well driller is unable to maintain ally of the above setbacks,
contact Catawba County Environmental Health at(828)465-8270
before drilling the welt
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(ISA NCAC I8A.3800). The fee for this
sampling is included in the cost of the well permit. It is the applicant or property owner's 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 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 xvater sample. For questions or more information.
please contact Catawba County Environmental Health at(828)465-8270.
04/24/2018
AUTHORIZED STATE AGENT APPROVAL DATE
Permit Expiration Date: 4/24/2023
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Parcel: 365602553940, 4692 RAINEY LN 1in=80ft
MAIDEN, 28650
This map/report product was preparod from the Catawba County,NC Geospatial Information Services. Catawba County has made substantial efforts
to ensure the accuracy of location and labeling information contained on this map or data on this report.Catawba County promotes and recommends
the Independent verification of any data contained on this maplreport product by the usor.The County of Catawba,its employees.agents,and
personnel,disclaim,and shall not be held liable for any and all damages,loss or liability,whether direct,indirect or consequential which arises or may
arise from this map/report product or the use thereof by any person or entity.
Copyright 2014 Catawba County NC
04/24/2018
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