HomeMy WebLinkAboutSAM-10-2019-123822.tifCase SAM-10-2019-123822
SM
CATAWBA COUNTY HEALTH DEPARTMENT
Environmental Health Section
WATER SAMPLE APPLICATION
Applicant D&E PROPERTIES, LLC, 7717 WINDY PINE CIR, DENVER NC 28037
B:7045303798
Site Address: 3659 KIMBER LN, SHERRILLS FORD NC 28673
Name of Subdivision:
Parcel Number: 368702976207 Lot: Block:
Specific Directions
Description: Retest
Reason for Sample: retest
SELECTED SAMPLES
Bacterial
10/23/2019
Type of Well 4010'lii'ir>4EIle'd` 1+:"!i,°n!E(i Is the well on this same property?
Is outside spigot available to collect sample? MWAWW Is power on?
Has well been tested before?�?F Ail+,t isi` 9
Results i a„
Does the plumbing come out the top of the well through a sanitary well seal? U1zi
Does the well ever become cloudy or has there ever been a problem with taste and/or odor? hikiAl ", NO
Explain
Does the well top extend twelve (12) inches above the ground or well slab?
The well is in: ' klratI'L'!li.�ilc.
Does this well supply water to more than one home?
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 timeframe r reporting results,
therefore, you may, receive several different reports concerning your water sample. F r estions or more i dr/maon,
please contact C�wba Count/Environmental Health at (828) 465-8270. n —
Date I ci / ' -I.-, 7 / 11 Signature or Owner or
AREAS
FEEDESCRIPTION!.
Bacteriological Sample Fee 10/23/2019 $58.00
TOTAL FEES �i...$5$.00.:...
rsamapplication 10/23/2019 Page 1 of 2
Sample Requested By
Property Address
Mailing Address _
Driving Directions —2
Catawba county
public health
lication
IA
Sample Requested: Bacteriological !/ Inorganic Chemical Other
Sample reason:
Type of Well: Drilled —IzBored Dug Other
Is the well on this same property? Yes —zNo
L.
Phone ;U 7` — -!�36 1�J k
ness
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? Yes4-1No
Is power on? Yes (, No %
Has well been tested before? Yes No Unknown Results 7LL, Y'/I-
/
Does the plumbing come out the top of the well through a sanitary well seal? Yes v No _ Unknown /
Does the water ever become cloudy or has there ever been a problem with taste or odor? Yes No I/
Explain
Does the well top extend 12 inches above the ground or well slab? Yes _&Z _ No Unknown
The well is located in front rear left side right side of the house.
Does well supp water to more than one home? Yes No
Date Signature of Owner or Agent
catawbacountync.gov
Environmental Health
Cotowba County Government Center
25 Government Drive I PC Box 389 1 Newton NC 28658 1 828.465.8270
MAKING. LIVING. BETTER.
CATAWBA COUNTY
100A SOUTHWEST BLVD
NEWTON, NORTH CAROLINA 28658
PHONE: 828.465.8399
w .catawbacountync.gov
PAYOR: D&E Properties, LLC
D&E Properties, LLC (Estes, Keith)
PAYMENTS
TRANSACTION NUMBER: TRC-9101159-23-10-2019
PAYMENT DATE: 10/23/2019
PAYMENTTYPE: Check 14679
NCDL- 8280078 DOB- 10/4/58 EXP- 10/4/24
RECEIPT
Wednesday, October 23, 2019
INVOICE NUMBER FEE NAME FEE AMOUNT
10-19-373461 Bacteriological Sample Fee $58.00
TOTAL PAYMENTS: $58.00
SAM-10-2019-123822
CASE TYPE: Water Sample WORK CLASS: Bacterial
SITE ADDRESS: 3659 KIMBER LN, SHERRILLS FORD NC 28673
Applicant D&E PROPERTIES, LLC, 7717 WINDY PINE CIR, DENVER NC 28037
13:7045303798
** NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 10/23/2019 10:07 Page I of I