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Home My WebLink AboutSAM-10-09-2216.tif $A C'~ Case # SAM-10-09-2216 CATAWBA COUNTY HEALTH DEPARTMENT Environmental Health Section 184 2 sM 10/30/2009 WATER SAMPLE APPLICATION APPLICANT OWNER CHARLES WILLIAMS CHARLES WILLIAMS 4825 GREY STONE LN 4825 GREY STONE LN MAIDEN NC 28650-9766 MAIDEN NC 28650-9766 Site Address 4825 GREY STONE LN, Maiden, NC Name of Subdivision Parcel Number 367702880130 Lot 12 Block Specific Directions HWY 16 S, LEFT ON AIRPORT RD, LEFT ON GREY STONE LN ON LEFT AT END OF CUL-DE-SAC 4825 ON MAILBOX Type of Sample BACTERIOLOGICAL 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 U 3 o Z voc Signature or Owner or Agent I 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 ke't 1 FEE DESCRIPTION DATE FEE AMOUNT Bacteriological Sample Fee 10/30/2009 $58.00 TOTAL FEES $58.00 10/30/2009 a $A C~ Case # SAM-10-09-2216 CATAWBA COUNTY HEALTH DEPARTMENT ~rr~ y U Environmental Health Section 184 2 5M 10/30/2009 APPLICANT OWNER CHARLES WILLIAMS CHARLES WILLIAMS 4825 GREY STONE LN 4825 GREY STONE LN MAIDEN NC 28650-9766 MAIDEN NC 28650-9766 Site Address 4825 GREY STONE LN, Maiden, NC Name of Subdivision Parcel Number 367702880130 Lot 12 Block j CATAWBA COUNTY, NC Environmental Health Boundaries i 1• ~NI f t fj F .f F AREA 2 ✓~~:eaa ~o E r1 /~j/ j~jl / j/ , E!j ~rr^' ~s 5 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. 10/30/2009 CATAWBA COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION Request for Water Sample T- Sample Requested By C~/ZS I~L~; ~L I m S Home Phone ~2- 7S State Road Number/Name L4 Al Business Phone SA m c- Ai fl rbvl Mailing Address i jc l S~ Name of Subdivisiori~~_ D 1 ~J7 f(i /A("(-)~i~ Lot # l 2- Section/Block Phase C~ Specific Directions le e. i Sample Requested for: Bacteriological- Inorganic Chemical Other Type of Well: Drilled V~ Bored Dug Other ( ) Is the well on this same property? Imo' yes no Is power on and is an outside spigot available to collect sample? l yes no Has well been tested before? des no (Results C 1 L 0 A-L ~N DYE ~ ~ ~Oy 3 ) 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: ~S S ~7f ~EPI•l 1 C,Vf~~tN ~U~ l 17~ des no Does the well top extend six (6) inches above the ground or well slab? es 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 amage that may occur. Date 0 c) ~ Signature of Owner or Agent i (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 Co CATAWBA COUNTY, NC 100-A South West Blvd Q, Newton, NC 28658- PERMIT RECEIPT Phone: (828)465-8399 Friday, October 30, 2009 184 2 sM www.catawbacountync.gov Permit Number: SAM-10-09-2216 Invoice Number: SAM-10-09-256792 Permit Type: Water Sample Receipt Number: RCPT-000377 Work Class: Bacterial Address: 4825 GREY STONE LN, Maiden, NC APPLICANT OWNER CHARLES WILLIAMS CHARLES WILLIAMS 4825 4825 GREY STONE LN GREY STONE MAIDEN NC 28650-9766 MAIDEN NC 28650-9766 FEE DESCRIPTION DATE FEE AMOUNT Bacterioloeical Sample Fee 10/30/2009 $58.00 TOTAL FEES $58.00 Date Payment Type Check Number Amount Change 10/30/2009 Credit Card $58.00 $0.00 Memo: Total Payment: $58.00 nc nin rcccipt ;iic,h , },I- tact-}? sn.3 c-c,I ~c i ~9jhf14; Ipt 10/30/2009 13:43 Page 1 of 1 1 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 10/30/2009 01:42PM Catawba 103 009134207476Eng 24317256 SAM-10-09-2216 CHARLES WILLIAMS I N/A WILLIAMS/CHARLES null null ************4664 Authorization and Capture Amount: $58.00 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. _ Signature click here to continue. https://www.velocitypayment. com/admin/catawbacountync/vpos/942/transactions/receipt... 10/30/2009