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HomeMy WebLinkAboutWELL-3-10-5501.TIF ~gA CATAWBA COUNTY Case # WELL-3-10-5501 G Subdivision F•r~ '2, Public Health Department Section/B1/Ph/Lot# Environmental Health Division v PO Box 389, 100A Southwest Blvd, Newton NC 28658 PIN# 1$ SM (828) 465-8270 Fax (828) 465-8276 TDD (828) 465-8200 Applicant/Owner Calin Seraz Site Address: 1347 Shadowfax W nd, Hickory, NC Property Size: 1.07 Directions: WELL PERMIT Proposed use: Private ® Public ❑ Semi-Public ❑ Other GROUTING DEPTH: MINIMUM 20 FEET SETBACKS: 1. 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. 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. SEE SITE PLAN FOR PERMITTED WELL LOCATION Megen McBride 3/17/10 ISSUED BY PERMIT ISSUANCE DATE CUSTOMER SIGNATURE DATE WELL INSPECTION: GROUTED DEPTH: 20' ❑ DATE: INITIALS: APPROVED CASING: PVC ❑ STEEL ❑ DATE: INITIALS: CASING HEIGHT 12' ABOVE LAND SURFACE ❑ DATE: INITIALS: WELL COMPLETION REPORT RECEIVED ❑ DATE: INITIALS: WELL HEAD APPROVED ❑ DATE: INITIALS: WATER SAMPLES TAKEN: BA ❑ IO ❑ N/N ❑ DATE: INITIALS: WELL DRILLER DATE DRILLED 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 rules 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 rules. The Well Completion Report must be submitted to the Health Department within 30 days upon completion of a well. CERTIFICATE OF COMPLETION AUTHORIZED STATE AGENT APPROVAL DATE ~NPR-3-~o - ~llo i I 7 ShadovJ6 INy►J• f pluo u1lct4 mu~ ewe o~;~ a~ such 0,6 ~ou-- (o+1 as 4o murG Y'll ra4141 A& S j+6 4o(l K a`ld ~raly tIA. ~ Ou4w, i5 -bo 4.eep s °~vi~ ~i (e, pYtOY AD S`~~t P,w° i Ia~ccon CA ON 4~ I o~ a57 SrAw s -(a "y- Yo 'tY1CS, -C-t~ from 10 Ja P ,0 3 bed►Od*- 0r C~ a . 51 x 5~ rr ro N 0(~ area te.~tly '1 0 td l ~06 !3 .o0 5 ~ 0'M ©t 60 H. Calin Seraz V 1347 Shadowfax Wynd, Hickory I84 sM Owner/Authorized Representative Acknowledgement of Permit Receipt 63 I certify that I am the owner or authorized agent (owner's authorization required) representing the owner of the property described above. As the property owner or authorized representative, I have received the above referenced permit(s) as requested in the application for service EHPR-3-10-4101, by the following method(s): CS Received in Person Facsimile Transmittal (Return form with signature required) Electronic Image Transmittal/ E-mail (Return receipt required) 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 .34-711D ~--Owner/Authorized Representative Signature CffG~~Ci SERA6 i (-/Date3 17 a o t'o Documentation of Permit(s) Transmittal (permit transmitted by electronic or other means) Permit transmitted by (name of person sending permit) Signature Date/Time Method: Fax Email US Mail Other Owner's request to send by the above indicated method of transmittal in lieu of signature acknowledges the conditions and statements above.