HomeMy WebLinkAboutWELL-4-11-17287.TIF �g CATAWBA COUNTY Case # WELL-4-11-17287
Public Health Department
�'� � Environmental Health Division Subdivision CROSSING CREEK
�'� "�' PO Box 389, 100-A Southwest Blvd, Newton, NC 28658 Lot # PT 15
8 '° P�# 376304841391
ApplicantlOwner Julia Thornton
Site Address: 3804 CROSSING CREEK DR, Claremont, NC
Properly Size: SF 0.49 ACRES
Directions: Hwy 70 to Rock Barn ERd / past CVS Pharmacy - stay on Rock Barn Rd - go to dead End turn Right - go to Deal Rd / Rt to
Crossing Creek Rd / Lot on Left.
WELL CERT'IFICA'TE OF COMPLE'TION
WATER SUPPLY: Vllell Type:
INSPECTIONS
INSPECTION# COMPLETED INSPECTION TYPE STATUS INSPECTOR
INSP-139156 OS/02/2011 EH Well Grouting Annroved Megen McBride
1NSP-139157 : OS/02/2011 EH Well Head Annroved Me;en McBride
INSP-139159 OS/02/2011 EH Well Certificate of Completion Annroved Megen McBride
, INSP-139160 OS/02/2011 EH Well Record Received Annroved EH Admin
Chris Russell-Russell Well Drilling 04/30/2011
WELL DRILLER DATE DRILLED
Well permits are valid for 5 years from the date of issuance and are subject to suspension and/or revocation fro 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 Deparhnent
within 30 days upon completion of a well.
Megen McBride 5/2/2011
AUTHORIZED STATE AGENT APPROVAL DATE
OS/02/2011 14:07
�gA CATAWBA COUNTY Case # WELL-4-11-17287
q � G Public Health Department Subdivision
Q � Environmental Health Division CROSSING CREEK
''�' PO Box 389, 100.A Southwest Blvd, Newton, NC 28658 Lot # PT 15
Ig 2 SM P�N# 376304841391
Applicant/Owner Julia Thornton
Site Address: 3804 CROSSING CREEK DR, Claremont, NC
Property Size: SF 0.49 ACRES
Directions: Hwy 70 to Rock Barn ERd / past CVS Pharmacy - stay on Rock Barn Rd - go to dead End turn Right - go to Deal Rd / Rt to
Crossing Creek Rd / Lot on Left.
WELL PERMIT
WATER SUPPLY: Individual Well
SETBACKS:
1. BUILDNG FOUNDATIONS 25 FT.
2. EXISTING & PROPOSED SEPTIC SYSTEMS - MIN.50 FT.
3. EXISTING & PROPOSED SEPTIC REPAIR AREA - MIN. 50 FT.
4. SEWAGE PUMI' SUPPLY LINE 50 FT.
5. UNDERGROUND STORAGE TANKS 100 FT.
6. STREAMSBROOKS/CREEKS 50 FT.
7. LAKES/PONDS RESERVOIRS 50 FT.
ALL OTHER POSSIBLE SOURCES OF GROUND WATER CONTAMINATION 100 FT.
The well driller must verify all setbacks before drilling the well.
If the well driller is unable to maintain any of the above setbacks,
contact Catawba County Environmental Health at (828) 465-8270
before drilling the well.
Grouting Depth: Minimum 20 Feet
Casing Height: 12" Above Land Surface
SEE SITE PLAN FOR PERMITTED WELL LOCATION
All newly constructed private drinking water wells in North Carolina are
required to be sampled in accordance with
15A NCAC 18A .3800 (Rules Regarding Private Drinking Water Well Testing).
The fee for this sampling is included in the cost of the well permit.
It is the applicant or property owner's responsibi{ity to notify Environmental Health
when the well is ready for sampling.
Megen McBride 04/25/2011
ISSUED BY PERMIT ISSUANCE
04/25/11 10:17
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� CATAWBA COUNTY . � , ,
G Public Health Department
Q 2 Subdivision CROSSING CREEK
� Environmental Health Division
"�' PO Box 389, 100-A Southwest Blvd, Newton, NC 28658 Lot # PT 1 �
! w P�N# 376304841391
Applicant/Owner 7ulia Thornton
Site Address: 3804 CROSSING CREEK DR, Claremont, NC
Property Size: SF 0.49 ACRES
Directions: Hwy 70 to Rock Barn ERd / past CVS Pharmacy - stay on Rock Barn Rd - go to dead End turn Right - go to Deal Rd / Rt to
Crossing Creek Rd / Lot on Left.
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-3-11-10036 , 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 andlor water supply well permitted.
Permit Issue Date: 04/25/2011 �
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.
04/25/11 ]0:17
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