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HomeMy WebLinkAboutSAM-2-10-4743.TIF $A C'~ Case # SAM-2-10-4743 CATAWBA COUNTY HEALTH DEPARTMENT v°Q Environmental Health Section '84 'L sM 02/16/2010 WATER SAMPLE APPLICATION APPLICANT OWNER PATRICIA HEGLER DARRIS SIGIVION 5589 E BANDY'S CROSS RD 1504 FOX DAIRY RD CATAWBA NC 28609- NEWTON NC 28658 (828)241-1236 282-465-5666 Site Address 5589 E BANDYS CROSS RD, Catawba, NC Name of Subdivision Parcel Number 368902557797 Lot Block Specific Directions HWY 16 S - TURN LEFT ONTO BUFFALO SHOALS RD - TURN RIGHT ONTO E BANDY'S CROSSROADS - 1.2 MILES ON RIGHT Type of Sample NEED BACTERIOLOGICAL WATER SAMPLE TO OPERATE A BAKERY Reason for Sample: Type of Well Drilled Bored Dug Spring City Is the well on this same property? yes 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 / ~ o to Signature or Owner or Agent ! ~C/J 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 AREA 1 FEE DESCRIPTION DATE FEE AMOUNT Bacteriological Sample Fee 02/16/2010 $58.00 TOTAL FEES $58.00 2/16/2010 CATAWBA COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION Request for Water Sample Sample Requested By `C Home Phone State Road Number/Name Business Phone Mailing Address_ q Name of Subdivision Lot # Section/Block Phase Specific Directions - DYL Sample Requested for: Bacteriological Inorganic Chemical Other Type of Well: Drilled B d Dug Other ( ) Is the well on this same property. yes no Is power on and is an outside spigot available to collect sample? ✓ 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? Explain: es l/ no Does the well top exten six (6) inches above the ground or well slab? yes no 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 property damage that may occur. Date & Signature of Owner or Agent Pot:Ecik-0- (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 A Cod CATAWBA COUNTY, NC 10 South West Blvd Newton, NC 28658- Newton, PERMIT RECEIPT V Phone: (828)465-8399 Tuesday, February 16, 2010 184 SM www.catawbacountync.gov Permit Number: SAM-2-10-4743 Invoice Number: SAM-2-10-259632 Permit Type: Water Sample Receipt Number: RCPT-800128 Work Class: Bacterial Site Address: 5589 E BANDYS CROSS RD, Catawba, NC APPLICANT OWNER PATRICIA HEGLER DARRIS SIGMON 5589 E BANDY'S CROSS RD 1504 FOX DAIRY RD CATAWBA NC 28609- NEWTON NC 28658 (828)241-1236 Payer: PATRICIA HEGLER Contractor: Fees: FEE DESCRIPTION DATE FEE AMOUNT Bacterioloaical Samnle Fee 02/16/2010 $58.00 TOTAL FEES $58.00 Payments: Date Payment Type Check Number Amount Change 02/16/2010 Cash $58.00 $0.00 Memo: Total Payment: $58.00 ~crnutreccipt ;r'}R3dc~-•131 1"%~1-hc6~-6~cae8kti57d1; rat 02/16/2010 13:47 Page 1 of 1