HomeMy WebLinkAboutWELL-3-11-15916.TIF ( gA • CATAWBA COUNTY Case # WELL -3 -11 -15916
' f �� Public Health Department
.i Environmental Health Division Subdivision
' "1' �' PO Box 389, 100 -A Southwest Blvd, Newton, NC 28658 Lot #
/8.2 w PIN# 373416746877
ApplicantlOwner DAVE KIZIAH ,G H pg _ 3- 1 %
Site Address: 1240 ELGIN DR, Conover, NC v
Property Size: SF 0.959 ACRES
Directions: HIGHWAY 16 N - TURN LEFT ONTO COUNTY HOME RD - TURN RIGHT ONTO SPRINGS RD - TURN RIGHT ONTO
HALL STREET - TURN LEFT ONTO ELGIN DR - 1ST HOUSE ON LEF
WELL ABANDONMENT PERMIT
Wells shall be abandoned in accordance with state regulations:
Article 15A North Carolina Administrative Code Subsection 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.
WELL TYPE
Dug
Susan Bumgarner 03/10/2011
ISSUED BY PERMIT ISSUANCE DATE
03/10/11 08:24
,',A • CATAWBA COUNTY Case # WELL -3 -11 -15916
�� G Public Health Department Subdivision
Environmental Health Division
7 r 7 kl) PO Box 389, 100-A Southwest Blvd, Newton, NC 28658 Lot #
18.2 M PIN# 373416746877
Applicant/Owner DAVE KIZIAH
Site Address: 1240 ELGIN DR, Conover, NC
Property Size: SF 0.959 ACRES
Directions: HIGHWAY 16 N - TURN LEFT ONTO COUNTY HOME RD - TURN RIGHT ONTO SPRINGS RD - TURN RIGHT ONTO
HALL STREET - TURN LEFT ONTO ELGIN DR - 1ST HOUSE ON LEF
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.
As the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service EHPR -3 -11 -9684 , by the following method(s):
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: 03/10/2011
Owner /Authorized Representative Signature
Date
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.
03/10/11 08:24