The URL can be used to link to this page

Home My WebLink AboutSAM-12-09-3090.TIF $A G~ Case # SAM-12-09-3090 CATAWBA COUNTY HEALTH DEPARTMENT U Environmental Health Section j 84 'L sM 12/03/2009 WATER SAMPLE APPLICATION APPLICANT OWNER TIMOTHY MILLER TIMOTHY MILLER 4078 LEFEVERS RD 4078 LEFEVERS RD VALE NC 28168 VALE NC 28168 (704)462-0777 (704)462-0777 Site Address 4078 LEFEVERS RD, Vale, NC Name of Subdivision a- "ems Avdo nte-d Parcel Number 267704912962 Lot 2 Block / S'4rflp1e' tjj~en jX+ JC,}-4 In Specific Directions s,nk e2Freele(5e p5mvs;5s~fS1~~ Type of Sample WATER SAMPLE Reason for Sample: Type of Well Drilled Bored Dug Spring City Is the well on this same property? lames no Is outside spigot available to collect sample? yes no Is power on? yes no Has well been tested before? yes no Results Does the plumbing come out the top of the well through a sanitary well seal? yes no Does the well ever become cloudy or has there ever been a problem with taste and/or odor? yes no Explain Does the well top extend twelve (12) inches above the ground or well slab? yes no The well is in: Front Rear left side right side of the house Is this well required to be tested anually for a semi public water source? yes no Does this well supply water to more than one home? yes no Date --3 --U!Y Signature or Owner or Agent ti An Environmental Health Specialist will contact you within 2 working days of application date. If you need further information or assistance please call 828-466-7291 FEE DESCRIPTION DATE FEE AMOUNT Inorganic Chemical Sample Fee 12/03/2009 $85.00 TOTAL FEES $85.00 12/3/2009 CATAWBA COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION Request for Water Sample .-mot Sample Requested By /M Home Phone 70 4 4 G Z- 6 7 7 State Road Number/Name 4 0 7 L E le U 0! ~t3c~U Business Phone Mailing Address L/ U 7 $ 1~C Yt ( 1 tt,c l1 t~~ Q N - r g) G 9 _ Phase Name of Subdivision Lot # Section/Block Specific Directions /0 LJej5-7- 7Z& rfan J~ RVAt { . 7-&f&1 /40-(i 0,5 S r, yvo a i C o C J_ C- 0 oZCrci ~ ~ 7- V C' IIJ R t~~ k, o q k e J t' Ve kcA . 6 U l?,1 e (-4 7-1-e- x,11 3-L- r yj k -Pr cc ~ Cr ~,J I ~ ~ X rt 13 7 eY tee % S Sample Requested for: Bacteriological Inorganic Chemical ✓Other Type of Well: _~Drilled Bored Dug Other ( ) Is the well on this same property? ✓no yes Is power on and is an outside spigot available to collect sample? yes _)L_no i?.rp r-s c c~5 ,^^ms~ S S i 5 Has well been tested before? yes no (Results , ()2 / ) AcSC ,.r) c Does the plumbing come out the top of the well through a sanitary well seal? des no Does the well ever become cloudy or has there ever been a problem with taste and/or odor? Explain: j1 S')) fur ~ I ( ~ es no yes no Does the well top extend six (6) inches above the ground or well slab? Ll~ The well is in: front rear ✓ left side right side of the house *Notes: Contact the EHS listed below to initiate the sampling. Wells must be inspected for proper construction before sampling. The owner or person requesting the sample is responsible for providing access to the well enclosure. If a county employee must remove any lid, cover or other item in order to gain access to inspect the well, the County is not responsible for any damage that may occur. By signing this document you agree to hold harmless Catawba County, its elected officials, employees and agents for any prope damage that may occur. Date Z - 3 c 91 Signature of Owner or Agent Sy Nil GX F Q'j LzL j I x C-1 i } .y`E Wrt r 3 CC /~-A . (For Office Use Only) Please Contact between 8 am and 9 am Phone Fee Date Paid Receipt # Initial White - Office Copy Yellow - Owner/Agent Copy V-POS - Transaction Receipt Page 1 of 1 Transaction Receipt Catawba County, NC Catawba County Permit Center 100 A SW Blvd Newton, NC 28658 828-4658404 12/03/2009 01:44PM Catawba 120309134350944Eng 25613872 SAM-12-09-3090 TIMOTHY MILLER 1 NA MILLER/ TIMOTHY GLENN null null ************7819 Authorization and Capture Amount: $85.00 Cardmember acknowledges receipt of goods and/or services in the amount of the total shown hereon and agrees to perform the obligations set forth by the cardmember's agreement with the issuer. ,l Signature click here to continue. https://www.velocitypayment.com/admin/catawbacountync/vpos/942/transactions/receipt/?... 12/3/2009 CATA"A COUNTY, NC l 00-A South West Blvd PERMIT RECEIPT Newton, NC 28658- V Phone: (82865-8399 Thursday, December 3 2009 84 sM www.catawbacountync.gov Permit Number: SAM-12-09-3090 Invoice Number: SAM-12-09-257719 Permit Type: Water Sample Receipt Number: RCPT-000742 Work Class: Inorganic Chemical Address: 4078 LEFEVERS RD, Vale, NC APPLICANT OWNER TIMOTHY MILLER TIMOTHY MILLER 4078 LEFEVERS RD 4078 LEFEVERS RD VALE NC 28168 VALE NC 28168 (704)462-0777 FEE DESCRIPTION DATE FEE AMOUNT Inorganic Chemical Sample Fee 12/03/2009 $85.00 TOTAL FEES $85.00 Date Payment Type Check Number Amount Change 12/03/2009 Credit Card $85.00 $0.00 Memo: ****7819 Total Payment: $85.00 permitreceipt;c94a512e-dbfa-431d-8b15-Oe9e8cafaee9;.rpt 12/03/2009 13:47 Page 1 of 1