HomeMy WebLinkAboutEHPR-4-11-10484 (2).TIF ~ ~ CATAWBA COLT~NTY HEALTH DEPARTMENT~~~~~~~~~~~'~~~~~
Telephone: (828) 465-8270 T D: (828) 465-8200 ~
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IP_AC,_~_Rpr. Prmt. pr. P t. •~Sys. Typ `"~~Well Prmt.~_Replacement Well Well Rpi~. Prmt.
Owner/Agent v ~~T ~ J,~~ ( Phone
Address ~ Subdivision ~
Sectio /Block/Phase Lot#
Lot Size ~ Directions:" -
Property Address ~ 3
Facility: House Mobile Home Business Multi-family .Other: Pin Number ~ C~ ~ ~ '
Other .Zoning Approval # 7.~c~ ~ Gr> L~ Z.
# Bedroomsy~ # Seats # Employees .Application Rate 3~ ,GPI) Flow ~
Hot Tub or Spa yes~Special Fixtures Basement yes/
t~ .100% Repair Are ~ /no
Basement Plumbing yes/no Water Supply: Private Well Public Semi-Public
Type of System: Trench Bed Pump Pump/Panel Panel LPP Other
Septic Tank Size Pump Tank Size Nitrification Field: Total Square Feet ~ Depth of Stone
Bed Size T e 'd~'i Total Length of All Trenches ~ Z Number of Trenches
Trench Length _ Feet on Center ~ Maximum Trench Depth ~Ej Distance of Nearest Well 'f"~Z~
*DO NOT INSTALL SEPTIC WHEN WET* *WELL RECORD REQUIRED AT COMPLETION*
Topo ( % Slope ~
Texture ~
Structure ~ ~
Clay Min. j ~ ~ ! ~
Soil Wetness ~ I
Soil Depth" ~ , i ~ ~ ~ d.
Restric. Hoz. at _ ~
Available space ye /no ~ ~ \
Overall Class S PS U ~
Comments: ~ \
~ ~ ~ Q
~ •
~ ~
I ~ I
~5
Filter Required I - - - - - ~
Riser required when ~ J
tank is more than 6 ~ l~C L~~ sF~
inches deep. ~
**NO GUARANTEE OR WARRANTY IS IMPLIED OR GIVEN AS TO THE PERFORMANCE OR LENGTH OF TIME THIS SYSTEM
WILL FUNCTION**
*Improvement Pcrnut has no expiration date and is transferable, but may be revoked if site plans or intended use changes for the proposed
facility. An Authorization to Construct is valid for (5) five years from date issued and is not transferable. Well Permit valid for 5 years
provided site conditions do not change. Well location, installation, and protection must meet state and local regulations, and must be
inspected and approved by a representative of the Catawba County Health Department before any portion of the installation is put into use.
The siting of the well by the Health Department staff is to provide protection fro 1 possible ~ urces of contamination. No volume of
water is guaran e d at any site by the Health Department. /1~/
Permit D ' Z~ - F~ C7 E
O er/Agen Septic Tank Installe y ~ ~ ~ ~ t4 ~ Date O~
EH - ; :e~ Well Installed By ~ - Well Grout Approval Date ~ - ~s- G`
Well Head Appro~%~1 Date 7` F y_: Date Sample Collected
Date of Results Results EHS ~ ~+y_-~•-°-'"
White -Office Blue - Building Inspection Operation Permit Yellow -Owner/Agent Green -Building Insj~ lion Authorization to Construct