The URL can be used to link to this page

Home My WebLink AboutSAM-3-10-5242.TIF ~$A CO Case # SAM-3-10-5242 CATAWBA COUNTY HEALTH DEPARTMENT Environmental Health Section 184 2 sM 03/09/2010 WATER SAMPLE. APPLICATION APPLICANT OWNER ROCKY WIMBERLY ROCKY WIMBERLY 2939 BALLS CREEK RD 2939 BALLS CREEK RD NEWTON NC 28658 NEWTON NC 28658 Site Address 2945 BALLS CREEK RD, Newton, NC Name of Subdivision Parcel Number 366903412400 Lot Block Specific Directions HWY 16 S, 5 MILES TAKE LEFT ON BALLS CREEK SCHOOL RD, GO 1/2 MILE LEFT AT ROCK ENTRANCE GO 200 YDS HOUSE ON LEFT. Type of Sample BACTERIA WATER SAMPLE 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 Signature or Owner or Agent 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 Bacteriological Sample Fee 03/09/2010 $58.00 TOTAL FEES $58.00 3/9/2010 $A CD Case # SAM-3-10-5242 H~ r- Ga CATAWBA COUNTY HEALTH DEPARTMENT Environmental Health Section 1 84 2 sM 03/09/2010 APPLICANT OWNER ROCKY WIMBERLY ROCKY WIMBERLY 2939 BALLS CREEK RD 2939 BALLS CREEK RD NEWTON NC 28658 NEWTON NC 28658 Site Address 2945 BALLS CREEK RD, Newton, NC Name of Subdivision Parcel Number 366903412400 Lot Block CATAWBA COUNTY, NC YL i Environmental Health Boundaries wi r;IGfOR7 i!JRvV tl : C. , f ' ON fJ V F 3 i.? ~ L^*a...+Fs~ f .d AREA 2 hs. tl' E . S Your application for Environmental Health (EH) services has been assigned to An Environmental Health Specialist (EHS) working in this area will contact you within two business days of receipt by the EH Division. If you are not contacted within this time, or if you would like to leave a message with an EHS, please call (828) 466-7291. Be sure to first state your case number from the top right corner of your application, and clearly state, your name, area number, and a number where you can be reached during normal business hours. 3/9/2010 CATAWBA COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION Request for Water Sample Sample Requested By C-k!j Home Phone a~Ys` ~Gz~ State Road Number/Name um I(s Cr re-k Sc, 44 t /Z -_e Business Phone ~1 - Vb'{- C~l~, -8so-s! 4 I Mailing Address Name of Subdivision Lot # Section/Block Phase Specific Directions w y f G S ,o 4- 5 m. f k P l e E SG, t, a Cc -G( C, e e k- ie 5C(16u" VQi.~ .~9 Y~'l'~•e ''D (p`oc. .Q.✓'Tr'/Jnit-4_ y iZO~ C~V-cQ~ Nb~'5e py Sample Requested for: Bacteriological Inorganic Chemical Other Type of Well: V'- Drilled Bored 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? des no (Results F-~ (e P ) 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: /1/o des no Does the well top extend six (6) inches above the ground or well slab? des 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 3-q- /-0 Signature of Owner or Agent P 'le1 (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 Cpl CATAWBA COUNTY, NC 1 00-A South tNC 286B58- d PERMIT RECEIPT a Phone: (828)465-8399 Tuesday, March 9, 2010 1$[}Z sM ~,,"vw.catawbacountync.gov Permit Number: SAM-3-10-5242 Invoice Number: SAM-3-10-260221 Permit Type: Water Sample Receipt Number: RCPT-800330 Work Class: Bacterial Site Address: 2945 BALLS CREEK RD, Newton, NC APPLICANT OWNER ROCKY WIMBERLY ROCKY WIMBERLY 2939 BALLS CREEK RD 2939 BALLS CREEK RD NEWTON NC 28658 NEWTON NC 28658 Payer: ROCKY WIMBERLY Contractor: Fees: FEE DESCRIPTION DATE FEE AMOUNT Bacteriological Sample Fee 03/09/2010 $58.00 TOTAL FEES $58.00 Payments: Date Payment Type Check Number Amount Change 03/09/2010 Check 4910 $58.00 $0.00 Memo: NCDL 1164459 EXP 3/19/15 D0133/19/45 Total Payment: $58.00 pennitreceipt,01004d5a-c109-40ha-b011'-?00:;b317dchb;.rpt 03/09/2010 10:29 Page 1 of 1