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Home My WebLink AboutSAM-2-11-14933.TIF �A a Case # SAM -2 -11 -14933 h fig CATAWBA COUNTY HEALTH DEPARTMENT :74. E nvironmental Health Section 1$ 4:-ism 02/03/2011 WATER SAMPLE APPLICATION APPLICANT 1 OWNER MARTHA B ROSS MARTHA B ROSS 1224 DIXIE ST 1224 DIXIE ST NEWTON NC 28658 NEWTON NC 28658 828 -695 -6414 828 - 695 - 6414 Site Address 1224 DIXIE ST, Newton, NC Name of Subdivision Parcel Number 364809164550 Lot 3 &4 Block Specific Directions HWY 321 TOWARD MAIDEN. RIGHT PAST McCREARY MODERN, TURN ON THE FIRST PAVED RD TO THE RIGHT. HOUSE IS FIRST HOUSE ON RIGHT, A CLAY COLORED CAPE COD HOUSE Type of Sample 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 A- 3 - I Signature or Owner or Agent 1,, _ 12(0/1/s/ 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 FEES SCRIPT10_N_—__ DATE __EFE AMOiINT Bacteriological Sample Fee 02/03/2011 $58.00 TOTAL FEES $58.00 2/3/2011 I • , - CATAWBA COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION Request for Water Sample , Sample Requested By Mt'' 6 IW S Home Phone t!l - IS 6 ce `l State Road Number/Name 1 as 4 i 'iJ X (e_, Business Phone 465 Mailing Address Va. a,q 0))( l F i 54 rQ e .,-61 '1\1 c aR 6 53 Name of Subdivision 2 ii Lot # Section/Block Phase Specific Directions \ 1Q 3 A l 'o u ox 3 `V d.Qn, 1R,1 a 11 � , V p N\c,UvArti - kt rn o n �-- -71(1-54. fa 60(k6, - - :- L ci h-h, . 0 k)c'$ k Ailu -F r ;� . 1/n u5e 0n A\AL et j h a - bal 0.01 alb c .off, 11,our2-1 Sample Requested for: Bacteriological )c Inorganic Chemical Other Type of Well: ___Drilled Bored Dug Other ( ) Is the well on this same property? X yes no Is power on and is an outside spigot available to collect sample? 2 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? ! v O Explain: yes no Does the well top extend 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 a i) '' \ Signature of Owner or Agent '( ) cs ka19/ (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 i V ' A e p� ~ CATAWBA COUNTY, NC �� "p° 10 Newton t NC 286 8 d PERMIT RECEIPT d+ ► Phone: (828)465 -8399 U 0 4 Thursday, February 3, 2011 /84 sm www.catawbacountync.gov Permit Number: SAM -2 -11 -14933 Invoice Number: SAM -2 -11- 271688 Permit Type: Water Sample Work Class: Bacterial Receipt Number: Site Address: 1224 DIXIE ST, Newton, NC APPLICANT OWNER MARTHA B ROSS MARTHA B ROSS 1224 DIXIE ST 1224 DIXIE ST NEWTON NC 28658 NEWTON NC 28658 828 - 695 -6414 FEES FEE DESCRIPTION DATE FEE AMOUNT Bacteriolo:?ical Sample Fee 02/03/2011 $58.00 TOTAL FEES $58.00 PAYMENTS PAYER: MARTHA ROSS Date Payment Type Check Number Amount Change 02/03/2011 Check 5376 $58.00 $0.00 Memo: NCDL 4689818 DOB 10/07/58 EXP 10/07/2016 Total Payment: $58.00 permit receipt { 1 e dacef -1 fbf -4a0d- 9143- 6f8Of28cead6 }.rpt 02/03/2011 08:24 Page 1 of 1