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HomeMy WebLinkAboutWELL-5-11-17846.TIF �B CATAWBA COUNTY Case # WELL-5-11-17846 � G� Public Health Department Subdivision � .� Environmental Health Division e ''� PO Box 389, 100-A Southwest Blvd, Newton, NC 28658 Lot # I8 'M P�N# 376112862861 Applicant/owner KEMP SIGMON Site Address: 2385 OLD ISLAND FORD RD, Claremont, NC Property Size: SF 89.62 ACRES Directions: OLD CATAWBA RD / JB RD / OLD ISLAND FORD RD WELL CERTIFICATE OF COMPLETION WATER SUPPLY: Well Type: INSPECTIONS INSPECTION# COMPLETED INSPECTION TYPE STATUS INSPECTOR INSP-143584 OS/11/2011 EH Well Grouting Annroved Megen McBride 1NSP-143585 06/08/2011 EH Well Head Annroved Megen McBride INSP-143587 06/08/2011 EH Well Certificate of Completion Annroved Megen McBride INSP-143588 06/10/2011 EH Well Record Received Annroved EH Admin INSP-146352 OS/24/2011 EH Well Grouting Annroved Megen McBride Jeff Speagle- Lake Norman Well 06/O1/2011 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 6/8/2011 AUTHORIZED STATE AGENT APPROVAL DATE 06/13/2011 1121 , , `�(�--�--�-� �. �, i�(,: �:�����:-��-�'�_��`,c���f 23�5 v� �` �j`�h�� il;�C� �.r�� ' � ` �a � �, f -���;;�� �vc ,�r;.�. ir�s Sc - �a fr�rn cre��� ,�,' j �, S s � ► �., ����,��, �;� �ab- , -�i-o�, �►� � ��.�r ` , 1C�-�a. . } � � 1 , �. � t r^ s-}r u c-}�x� S, � f � (� �, � C o�II�I p S Gr^� fe�q�r �,�rr�, t iti�� �� �On+YXJ� C' rl�� Y1'''t.•_ �' �.� �� ` 1�� � 1 � � � `� > �1) �1e If '� �W' " 4 �� Y80Nti^ S� �`'� G � � b�; 3 bQ�`y�-� ���� � o � � J �k n U�� � � ,'1 , ( � _ � /bO�F.� -}-� L-}4' {�'., �. 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'': � �� 1' ` ,�c- ,�r c�l. �1� c•ts ,� jq � ���, X BC� ,' �:. �ep}�c, „f rZO�ir�. l�p,_ , � 4 "' � � �u"k � lofd ��.ir�.- `�kis ��� � / (��L �So (c �.5 � 5�+�5 a °"�-----� � 30� , 0.� �. � ,r � �t�� -- - -- - -, - `E �i(.- c 'r'�1!� �re� i ht7�Z br w�T t�S S�I�, a��• ��� ����� xy,_� � _ / `�iJ �� �,�i Sea �'�'J I . � �- � T 1''-1oc' ,y�S,� CATA��'6.4 COUN'1'Y Cx,c � Public i lealth llepanment /� �'>. suhd�vision j '� • � [nviroumrntal Hcalth Di��isiun f."I � 'N�� ��� NC) Boz 3g9. IGO•A Soulht�est Blvd, Nc�clim, NC. 28ti�b \�4i PIN� ;7ti1I28G28Gi ApplicanUOwner KF,1��iP SIG�10N Site AddreSS: 23R5 OLU IS1.A�D FORU RD. Claremont, \C Property Size: SP 89.62 ACRES DireCtions: OLb CA �nWBA KD i JB Kf:� ; C)LU ISLaND FORU RD Q�vner/Authorized Representative Acknowtedgement of Permit �teceint � I certify that t am the owner or authorizcd a�ent (owner's authorization required) represcntine the ow�ner of the property described above. � 11s the propert�� owner or authorized representative, I have received the above referenced permit(s) as requested in the aJ�Plication for service F,HYR-4-11-10694 , hy thc i�llowing method(5): Received in Person Facsimile 1�ransmittal (Return fonn with sianature requiredl _ Electronic Image Transmitlal! E-mail (Return receipt required) As the property owner or authorized representative I havc re��ie���ed and understand the specific conditions of the pennit issued, and turther understand that all apE�licable regulatory requirements specitied under the North Carolina Laws and Rules for Sew�a�e Treatment and Disposal 5ystcros (15A NCAC 18A .1900), and/or Welt Construction Standards (15A NCAC 2C A100), shall apply to the issuance of this permit and the construction of the ��-aste��ater system and/or water supply ti�ell permitted. Pern�it Issue Date: pj! � p/�p � � . -- Owner/Authorized Representative Signature _ Date � ----------------------------------------------------------------------------------------------------------- Uocumcntation of Ycrmit(s)'1'ransmittal (permit transmitted by electronie or othcr means) Perniit transmitted b�• tnain� o ��per.son se:n�lir�g perrriil� Signature _ DateiTime Mcthod: Fax Email US i�lail Uther O«�ner's request ko send by the abo��e indicated method of transmittal in lieu of signature ackno���ledges the conditions and statcments abuve. os�ivii os:is �+ � ��,�� Vy$T,� CO�'$�G�I�PI RECO� � Nonk Cuokau► Asp�r�e�t of Fs►+�auncnt md �laouat Reswr.zs- Di.'aioi a(V4�ata ¢.u�l4ty ���»"�'� � ��- WF1.L COriTRACTOR CFA'1�1CATl4N �! �. vr�al. c�orrr�+ct'o�: t. 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