HomeMy WebLinkAboutWELL-1-10-4332.TIF
Case # G P2-1- 0- 532.
- CATAWBA COUNTY
G.
Subdivision Health Department Section/BI/Ph/Lot# 2
Environmental Health Division PIN# 3jll-a~-70 - 5~
PO Box 389, 100A Southwest Blvd, Newton NC 28658
1 g 42 sm (828) 465-8270 Fax (828) 465-8276 TDD (828) 465-8200 L
Applicant/Owner i de 0 -In Lo un
Site Address: 1773 efbie, 're rn4 h !dL
Property 0,62 t t5
Directions:
WELL PERMIT
Proposed use: Private Public ❑ Semi-Public ❑ Other
GROUTING DEPTH: MINIMUM 20 FEET
SETBACKS: W
I. BUILDING FOUNDATIONS 25 FT. 5. UNDERGROUND STORAGE TANKS 100 FT.
2. EXISTING & PROPOSED SEPTIC SYSTEMS MIN. 50 FT. 6. STREAMS/BROOKS/CREEKS 50 FT.
3. EXISTING & PROPOSED SEPTIC REPAIR AREA MIN. 50 FT. 7. LAKES/PONDS RESERVOIRS 50 FT
4. SEWAGE PUMP SUPPLY LINE 50 FT. C3'
ALL OTHER POSSIBLE SOURCES OF GROUND WATER CONTAMINATION 100 FT.
The well driller must verify all separations are adhered to before drilling the well.
If the well driller is unable to maintain any of the above separations, contact the Health Department at (828) 465-8270 before drilling the well.
SE SITE PL N FOR PERMITTED WELL LOCATION
10
AS-_ D PERMIT ISSU NCE ATE
OMER "TKR DATT
WELL NSPECTION:
GROUTED DEPTH: 20' DATE: INITIALS:`
APPROVED CASING: PVC STEEL DATE: Z (0 INITIALS: Amtk
CASING HEIGHT 12' ABOVE LAND SURFACE DATE: b~- 10 INITIALS: 446
WELL COMPLETION REPORT RECEIVED 1Q~ DATE: 3 J `1 D INITIALS:
WELL HEAD APPROVED DATE: 41' ~U INITIALS: 1~t
WATER SAMPLES TAKEN: BA ❑ IO ❑ N/N ❑ DATE: INITIALS:
WELL DRILLER DATE DRILLS
Well permits are valid for 5 years from the date of issuance and are subject to suspension and/or revocation for non-compliance with
appropriate state and local roles and regulations, or if false information was given in order to obtain a permit. Wells shall be constructed in
accordance with all state and local regulations and roles. The Well Completion Report must be submitted to the Health Department within 30
days upon completion of a well.
CERTIFICATE OF COMPL T ON
b
AUTHOR IZ q STAT AGENT APPROVAL DA E
~$A CATAWBA COUNTY Case # LAPP-- I-1o-3532-
•
Public Health Department Subdivision
G Environmental Health Division Section/BI/Ph/Lot# 2
~P~ PO Box 389, 100A Southwest Blvd, Newton NC 28658 PIN# -20 - 70 - $
(828) 465-8270 Fax (828) 465-8276 TDD (828) 465-8200
1842 sM
Applicant/Owner a eye L)PIM (A Q
Site Address: 1-773 er ie ew n NG
Property Size:
Directions:
Improvement Permit ❑ Authorization to Construct ❑ Well Permit
SITE PLAN
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50, 50'
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System c mponents represent approximate contours only. The contractor must flag the system prior to beginning the installation to ensure that proper grade is maintained. Do not
install s) under wet c ditions. This pen it is subject to revocation if the site plan or site conditions are altered.
AUTHORIZE TATE AGENT DATE
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