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HomeMy WebLinkAboutSAM-12-09-3366.TIF $A~ Case # SAM-12-09-3366 h i Ga CATAWBA COUNTY HEALTH DEPARTMENT v Environmental Health Section 1 g 4 2 sM 12/15/2009 WATER SAMPLE APPLICATION APP IL IL CAN ~_.O ENW R-.,~~~Y. - - - ; 1 ROBERT BOX 8 CCRACKEN l 170 SKY DOLT 1 PO NEWTON NC 28658- NEWTON NC 28658 - (508)965-0756 Site Address 1170 SKY DR, Newton, NC Name of Subdivision Parcel Number 374019714 01 Lot 9-11 P'1'8 Block B Specific Directions Type of Sample BACTERIOLOGICAL 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 AREA 1 FEE DESCRIPTION DATE FEE AMOUNT `Bacteriological Sample Fee' 12/ 15/2009 $58.00` TOTAL FEES $58.00 12/15/2009 S3A C'~ Case # SAM-12-09-3366 CATAWBA COUNTY HEALTH DEPARTMENT V ®a~~ Environmental Health Section 184 2 sM 12/15/2009 APB PLICANT O.WNE}2 r ROBERT 1VICCRACKEN < 'ELISSA kOLT PO BOX 8 1170 SKY DR NEWTON NC 28658- NEWTON NC 28658 (508)965-0756 Site Address 1 170 SKY DR, Newton, NC Name of Subdivision Parcel Number 37401971401 Lot 9-11 PT s Block a i y 4~ CATAWBA COUNTY, NC Environmental Health Boundaries f- j ti -<cnv _¢o ~ y r ~ f`ipp C Ej C~ l~ nn - ✓ h N. ~ AREA 2 S Your application for Environmental Health (EH) services has been assigned to AREA 1 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. 12/15/2009 $A ~O Case # SAM-12-09-3366 h I~~~' y CATAWBA COUNTY HEALTH DEPARTMENT V 7~~ Environmental Health Section j $ 4 sm 12/15/2009 WATER SAMPLE FIELD REPORT APPLICAMf QWNER J ROBERT MI:C:'KA(U<LN ' MFLlSSA HUL 1 PO BOX 8 1170 SKY DR NEWTON NC 28658- NEWTON NC 28658 - (508)965-0756 Site Address 1 170 SKY DR, Newton, NC Name of Subdivision Parcel Number 374019714501 Lot 9-11 PT s Block B Specific Directions Initial Collected by: Date/Time Sampled: Type of Sampling Point: Well New or Existing? New Existing Type of Well: Drilled Bored Dug Spring City Resample collected by: Date/Time Sampled: Date of Well Installation: Reason for Sample: Does well meet adequate construction standards from what can be observed: Yes No Reason for non-compliance: Defective well cap and / or seal Piping does not exit through top of well by approved cap and sanitary well seal Evidence of improper grouting or no grouting Opening in the well casing or cap Supply too close to source of potential contamination Notification: Existing well owner notified that well does not meet adequate construction ? Yes No Date of Notice: Improvement: Existing well improved Yes No Date of Inspection: 12/15/2009 v' A C~ Case # SAM-12-09-3366 CATAWBA COUNTY HEALTH DEPARTMENT V Environmental Health Section 184 Z sM 12/15/2009 WATER SAMPLE TEST RESULTS ROBERT MCCRACKEN MELISSA HOL I PO BOX 8, . 1'170 SKY DR. NEWTON NC 28658- NEWTON NC 28658 (508)965-0756 Site Address 1 170 SKY DR, Newton, NC Name of Subdivision Parcel Number 374019714501 Lot 9-11 ["1'8 Block B Specific Directions Lab Coliform Analysis Results: Total Coliforms: Fecal / E. Coli: Invalid Results: No Collection Date Over 30 hours old Excessive turbidity Excessive Chlorine Lab Accident Lab Tech Initials Date/ Time Received Date/ Time Completed 12/15/2009 Catawba Q unty P~blic Health Department Print Form c ! y~ SV- Environmental Health Division Request for Water Sample _ l ~ ie 184P2 SM r + Sample Requested By: n Home Phone: ~,ir-t ` '7 r tom, ( t. t , 0- State Road Number/Name: IOC) Jk f ~I ~~..76 IV Business Phone: F Mailing Address: t Name of Subdivision Lot #:F Section/Block Phase: F 1 Specific Directions: f ,J au I~ r i t ' + f RCS C-d 1 Sample Requested for: (~✓Bacteriological Wrl organic Chemical Other Type of Well: F- Drilled F` Bored F- Dug Other Flo 7 t r Is the well on this same property? JYes F No is the power on and is an outside spigot available to collect a sample? F--/Yes F No Has the well been tested before? Yes F- No Results: J ~C7 ~ Ai l Does the plumbing come out the to of the well through a sanitary well seal? r' P F Yes F No Does the well ever become cloudy or has there ever been a problem with taste and/or order? Yes F No ~J L C~ ti if yes, explain Does the well top extend six (6) inches above the ground or well slab? F Yes F No The well is in: F- Front F- Rear F- Left Side [-t.-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: 1 L v ( Signature of Owner or Agent r j (For Office Use Only) f - Please Contact: o ,er t TI(7 J0 r01-r l )n1 Between E am and gam Phone: Fee F Date Paid Receipt # F Initial CATAWBA COUNTY, NC 100-A South West Blvd Newton, NC 28658- PERMIT RECEIPT V s®P® a Phone: (828)465-8399 Tuesday, December 15, 2009 184 sM www.catawbacountync.gov Permit Number: SAM-12-09-3366 Invoice Number: SAM-12-09-258035 Permit Type: Water Sample Receipt Number: RCPT-000850 Work Class: Bacterial Address: 1 170 SKY DR, Newton, NC T - WPPLICXNT`~--_, - OWNER ROBERT'MCCRACKEN•..'' - MELISSA H©LT - PO BOX 8 1170:SKY'DR NEWTON'NC 28658- NEWTON NC 28658 (508)965-0756 FEE DESCRIPTION DATE FEE AMOUNT t Ba? ~ cterioloaical Sample Fee 12%15%2009. $58'00 " TOTAL FEES $58.00 Date Payment Type Check Number Amount Change $0.00. 12/15%2009 Credit Card $58'.00 Memo: ****4138 Total Payment: $58.00 pcrroitreceipt;~i11245b9-VSI~-~~ibf'-alr9-2c~e611'?h7il',.ipt 12/15/2009 12:29 Page 1 of1 V-POS - Transaction Receipt Page 1 of 1 Transaction Receipt i Catawba County, NC Catawba County Permit Center 100 A SW Blvd Newton, NC 28658 828-4658404 12/15/200912:14PM Catawba 121509121108432Eng 26105856 SAM-12-09-3366 ROBERT MCCRACKEN 1 N/A I ROBERT C MCCRACKEN 537 HART ST 02715 j ************4138 i i 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 ~l i i i I click here to continue. i i i i i i i https://www.velocitypayment.com/admin/catawbacountync/vpos/942/transactions/receipt... 12/15/2009