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Home My WebLink AboutSAM-12-09-3338.TIF $A CO~ Case # SAM-12-09-3338 CATAWBA COUNTY HEALTH DEPARTMENT Environmental Health Section jg 4sM 12/14/2009 WATER SAMPLE APPLICATION APPG[CAN1'.< OWNER TROYED\VARlls fZOCI<1' WIIti1liLRLY 2945BA11LS CREEK RD. 2939, BALLS CREEKRD NEWTON NC 28658- NEWTON NC 2868 (828)465-8331 Site Address 2945 BALLS CREEK RD, Newton, NC Name of Subdivision Parcel Number 366903412400 Lot Block Specific Directions Type of Sample BACTER. WATER SAMPLE Reason for Sample: Type of Well Drilled Bored Dug Spring City Is the well on this same property? yes ono 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? es 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 /2" Signature or Owner or Agent j~ . 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 AREA 1 FE E.,nESCRIPTInN- _ __._.DATE FEE AMOUNT Bacteriological Saniple Tee 12/14/2009 `$58:00 TOTAL FEES 558.00 12/14/2009 CATAWBA COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION 3$ Request for Water Sample Yl~~~'y57 Sample Requested By ,I/'d X r Home Phone ~ Z?IS& /~S CrC~~ Business Phone Ye S' State Road Number/Name Mailing Address 2 Ic~s ~'~O ~1S ~~~L~ ~Q~ /~e~ fl~.✓ 2 <?Z. 'S4 Name of Subdivision Lot # Section/Block Phase Specific Directions 117110261S uli 1i0) (Ac y,6 I,-- t 61 Q ~nD Sample Requested for: Bacteriological Lll~ Inorganic Chemical Other Type of Well: 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? -z-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: ' / yes L/ ` 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 i/ 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 d a e that may occur. Date /2 ` ~ Q9 Signature of Owner or Agent (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 gA -C0 CATAWBA COUNTY, NC 100-A South West Blvd On/~ Newton, NC 28658- PEIT IYII T RECEI PT oC~ Phone: (828)465-8399 Q), > a®~~. , `4' Monday, December 14, 2009 1$ sm www.catawbacountync.gov Permit Number: SAM-12-09-3338 Invoice Number: SAM-12-09-257998 Permit Type: Water Sample Receipt Number: RCPT-000833 Work Class: Bacterial Address: 2945 BALLS CREEK RD, Newton, NC APPUTCANT _ -OWNER TROD EDWARDS ROCKY V,.' f, IBLRLY V_ J 2945. BALLS CREEK RD 2939 BALLS CREEK RD- NEWTON NC 28658 NEWTON ,NC 28658 (828)465-8331 FEE DESCRIPTION PATE FEE AMOUNT OIe- - 12-1 1-1 -'009 $58.00 L1a.;terolo~ica1 Sam TOTAL FEES $58.00 Date Payment Type Check Number Amount Change 12/14/2009 -Cash ,$58.00 $0.00 Memo: Total Payment: $58.00 permit receipt 3cbayr_'-c7e4-4cft?-$17N Ibe?c 11110d0 .ipt 12/14/2009 13:47 Page 1 of 1