HomeMy WebLinkAboutSAM-9-10-10954.TIF RECEIVED
^� ` ` �� � _ � Catawba County Public Health Department Print Form
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���� Environmental Health Division
J��'o` CATAW8A COUNTY Request for Water Sample
s ENVIRONMENTAL HEALTH
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Sample Requested By: !Donald Innes Home Phone: 1704- 483 -4346
State Road Number /Name:16629 Love Point Rd. Business Phone: 1828- 446 -9387
Mailing Address: 6255 Hwy 150 E., Denver, NC 28037
Name of Subdivision Norman Country Estates Lot #:F1 Section /Block Phase:
Specific Directions:116 south, left on 150, right on Grassy Creek, left on Love Point Rd., 3/4 mile on the right. Post at road has house
}number on it, black top driveway leads back in behind other homes to this home.
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Sample Requested for: Ix Bacteriological Ix Inorganic Chemical Other
Type of Well: Ix Drilled (` Bored r Dug Other 1
Is the well on this same property? EX Yes I No
Is the power on and is an outside spigot available to collect a sample? fX Yes I No
Has the well been tested before? E Yes rX No Results: 1
Does the plumbing come out the top of the well through a sanitary well seal? r` Yes r No 1 `4 kYtow
Does the well ever become cloudy or has there ever been a problem with taste and /or order? Yes IX No
If yes, explain
Does the well top extend six (6) inches above the ground or well slab? lX Yes I" No
The well is in: EX Front I Rear I 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 damage that may occur.
Date: 19-9-10 Signature of Owner or Agent I C
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(For Office Use Only)
Please Contact: 1 Between 8 am and 9am Phone: 1
Fee I Date Paid 1 Receipt # Initial 1
g 'A Cp CATAWBA COUNTY, NC
� �' ' , 100-A South West Blvd
fi Newton, NC 2$658- PERMIT RECEIPT
•V .:, j �� , Phone: (828)465 8399 Friday, September 10, 2010
\� www.catawbacoun nc. ov
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Permit Number: SAM -9 -10 -10954 Invoice Number: SAM -9 -10- 266851
Permit Type: Water Sample
Work Class: Multiple Different Samples Receipt Number:
Site Address: 6629 LOVE POINT RD, Denver, NC
APPLICANT OWNER
Donald Innes Donald Innes
6255E Hwy 150 6255E Hwy 150
Denver NC 28037 Denver NC 28037
Contractor:
FEES
FEE DESCRIPTION DATE FEE AMOUNT
Bacterioloeical Sample Fee 09/10/2010 $58.00
Inorganic Chemical Sample Fee 09/10/2010 $85.00
TOTAL FEES $143.00
PAYMENTS
PAYER: DONALD INNES
Date Payment Type Check Number Amount Change
09/10/2010 Check 9708 $143.00 $0.00
Memo: RECEIVED BY MAIL.
Total Payment: $143.00
permit receipt , c17dG46S- ,_6b -4eh6 )]17- ft)ha.bcUabe;.rpt 09/10/2010 11:35 Pagel oft