HomeMy WebLinkAboutWELL-06-2022-174466.tif 41,.VAIrtit a CAT dtWBA COUNTY
-)-Kt Public Health Department Subdivision CRESCENT LAND AND TIMBI
s Environmental Health Division PINM 460715649298
' PO Box 389,25 Government Drive,Newton,NC 28658 LOTn 122
tilt .0
Sits Address: 3837 CHEVLOT HILLS RD. SHERRILLS FORD NC 28673
Munson Permit GOPHER UTILITY SERVICES INC
Property 81zs: Acres 0 68
Directions: NC 16 Bus,left onto NC 150,left onto Cheviot Hills Road
Owner/Authorized Representative Acknowledgement of Permit Receipt
I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
,/K As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service EHPR-06-2022-41389, by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
J Electronic Image Transmittal/ E-mail (Return receipt required)
k! 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(15A NCAC 18A.1900),
and/or Well Construction Standards(15A 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:06/2 3120 2 2
\:•
Owner/Authorized Representative Signature 1
Date Li(ZC111O271
Documentation of Permlt(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature ] Date/Time LOP8j' )
Method: Fax J 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 yor<Please ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.corn/s/EHCumomerservice
06n4n017 oa 40 le r
=�� CATAWBA COUNTY Case# WELL-06-2022-174466
i.y(....,•t.I ,2 Public Health Department Subdivision CRESCENT LAND AND TIMBE
d • '-1 Environmental Ilealth Division PIN# 460715649298
PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 122
w
Site Address: 3837 CHEVLOT HILLS RD, SHERRILLS FORD NC 28673
Name on Permit: GOPHER UTILITY SERVICES INC
Property Size: Acres 0.68
Directions: NC 16 Bus, left onto NC 150, left onto Cheviot Hills Road
WELL ABANDONMENT PERMIT
Well Type: Drilled
Wells shall be abandoned in accordance with state regulations:
Article 15A North Carolina Administrative Code Subchapter 2C
The Well Abandonment Report must be submitted to the Catawba County Environmental Health within
30 days upon completion of a well abandonment.
Well contractor must schedule well abandonment inspection with Catawba County Environmental Health.
a. le...-101"te /r:kt RSl 06/23/2022
Authorized State Agent Permit issuance Date
6/23/2027
Permit Expiration Date
eIipei m it 06/27/2022 10:29
, Catawba County Environmental Health
14--, l( - 6 - 202."z- ( 7 I Y
,-?,, 1,-, t( -‘ - 2 0 zz- ( 7(4 if b 6 (AtijI
•jk
•3825
,�J
0
'1-
•
/ Oj.
qb
[1‘ 1 0' /
r,
.19
'e J 1,yry`O �7 irr�•
Ho tile -
kr.I.1 r •3837 e
,,,,` q9 yI7 C YJ _.!1
w tit }D 1.1r: :)
P.
r , bt ^b,^J•n
Yip 1 T `'.
I•Al W M1 i
LY ;t..a 3 :a y M1, i
_r _ r 7
, R 7 -y rik i - -o
it.',r `,19 1 ;• i ,� r y 1,, y2• 1.
+'y, y w J >r, 1
}
Parcel: 460715649298, 3837 CHEVLOT HILLS 1in=50ft
RD SHERRILLS FORD, 28673
This map/report product was prepared from the Catawba County,NC Coos M1atlel Information Sorvlcos. Catawba County Itaa made substantial odbtts
to ensure the accuracy of location and labeling information contained on this map or data on lhls roport.Catawba County promotes and recommend
the independent verification of any data contained on this map/report product by Iho user.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 dli'oul,Indirect or consoquontlel which arises or may
arise from this map/report product or the use thereof by any person or entity,
Copyright 2021 Catawba County NC
0G121/2022