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Home My WebLink AboutSAM-05-2018-098981.TIF g$A' , Case SAM-05-2018-098981 2 CAFAWBA COUNTY HEALTH DEPARTMENT .r Environmental Health Section /8 . 'L sM 05/0112018 WATER SAMPLE APPLICATION Applicant MANDY BARR,7633 MONRO RD CAIAWBA NC 28609 0:7049297291 Site Address: 1990 BROWN CHAPEL RD, CATAWBA NC 28609 SELECTED SAMPLES Bacterial Name of Subdivision: Parcel Number: 470103225637 Lot: Block: Specific Directions Description: For purchase of home Reason for Sample: buying home Type of Well Drilled Is the well on this same property? - Yes Is outside spigot available to collect sample? Yes Is power on? Yes I las well been tested before? Unknown Results Does the plumbing conic out the tap of the well through a sanitary well seal? Unknown Does the well ever become cloudy or has there ever been a problem with taste and/or odor? NO z: Explain Does the well top extend twelve(12)inches above the ground or well slab? Yes the well is in: Left Side Does this well supply water to more than one home? No 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.youmay receive several different reports concerning your water sample_ For questions or more information, please contact Catawba County Environmental I lealth al(8281465-8270. Dale Signature or Owner or Agent Area 1 FEF DESCRIPTION DATE FEE AMOUNT Bacteriological Sample Fee 05/01/2018 $58.00 TOTAL FEES $58.00 rsamapplication 5/1/2018 Page 1 of 2 �ATAWBA Catawba County Public Health " 'Print<g COUNTY '.K' wv.",+.catawbacountync.gov/environmentalhealch rte' Environmental Health North carotins P.O.Box 389,25 Government Drive, Newton, NC 28658 Phone(828)465-8V0 Fax(828)465-8276 ��//;�II te��TTTl.... /� Water Sample Application ,/ ] 7 Sample Requested By /97,717 E/'/. Home Phone S� ar9 -729/ Property Address / !d / P V / 9 /12 to bd.") /341,,.4L usin//2ss/Phone Ne fr/ p Mailing Address 2 '-"`1' sio„Qj N ,711 (2/ Driving Directions . L - /`_, %/.i d .a ' zfe j,, I Sample Requested: BacteriologicalV Inorganic Chemical Other Sample reason: tL(..///itor {^,/ M U /::-F- Type of Well: Drilled ✓ Bored / Dug Other Is the well on this same property? Yes ✓ _No PLEASE NOTE:Sample will be taken at the well head.If well head is not accessible,sample will be taken from a spigot on outside of home,unless otherwise specified: Is outside spigot available to collect sample? Yes V(No Is power on? Yes ✓ No Has well been tested before? Yes No_ Unknown V/ Results Does the plumbing come out the top of the well through a sanitary well seal? Yes No Unknown V" Does the water ever become cloudy or has there ever been a problem with taste or odor? Yes No Explain Dues the well top extend 12 inches above the ground or well slab? Yes ' ' _No_ Unknown The well is located in front I/ rear left side right side of the house. Does well supply water to more than one home? Yes No ✓ ry/ Date / %1/4D/rK Signature of Owner or Agent 927 /� � "Leading the Way to a Healthier Community" 0 4°1 {r t=Pubiic e: 7 s'sHealth ?I V 7.‘C314: CATAWBA COUNTY bin G� 100A SOUTHWEST BLVD 111 NEWTON,NORTH CAROLINA 28658 RECEIPT PHONE:828.465.8399 1759 0 7 Tuesday,May 1,2018 1842 5M www.catawbacountync.gov PAYOR: Barr,Mandy PAYMENTS TRANSACTION NUMBER: TRC-3529146-01-05-2018 PAYMENT DATE: 05/01/2018 PAYMENT TYPE: Credit Card 203511702 INVOICE NUMBER FEE NAME FEE AMOUNT 05-18-352420 Bacteriological Sample Fee $58.00 TOTAL PAYMENTS: $58.00 SAM-05-2018-098981 CASE TYPE: Water Sample WORK CLASS: Bacterial SITE ADDRESS: 1990 BROWN CHAPEL RD,CATAWBA NC 28609 Applicant MANDY BARR,7633 MONBO RD,CATAWBA NC 28609 C:704929729I **NO PEOPLESOFT ACCOUNT ASSIGNED** receipt 05/01/2018 16:02 Page 1 of 1