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Home My WebLink AboutSAM-3-10-5614.TIF $A CO Case # SAM-3-10-5614 CATAWBA COUNTY HEALTH DEPARTMENT Environmental Health Section j$ tJ~Z sM 03/19/2010 WATER SAMPLE APPLICATION APPLICANT OWNER BUILDING SYSTEMS OF CATAWBA CO BUILDING Darrell Matthews SYSTEMS OF CAT CO 9310 W NC l0 HWY PO BOX 3409 Vale NC 28168 HICKORY NC 28603 8283276677 Site Address 9310 W NC 10 HWY, Vale, NC Name of Subdivision Parcel Number 266703429478 Lot Block Specific Directions Type of 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 Ac;~ FEE DESCRIPTION DATE FEE AMOUNT Bacteriological Sample Fee 03/19/2010 $58.00 TOTAL FEES $58.00 3/19/2010 $A C'0 Case # SAM-3-10-5614 CATAWBA COUNTY HEALTH DEPARTMENT Environmental Health Section Mob, 1842 sM 03/19/2010 APPLICANT OWNER BUILDING SYSTEMS OF CATAWBA CO BUILDING Darrell Matthews SYSTEMS OF CAT CO 9310 W NC 10 HWY PO BOX 3409 Vale NC 28168 HICKORY NC 28603 8283276677 Site Address 9310 W NC 10 HWY, Vale, NC Name of Subdivision Parcel Number 266703429478 Lot Block CATAWBA COUNTY, NC i&ie Environmental Health Boundaries / J 1 J 2I ~ ` `I (HICKOP 4 1 I k• 1• \ os~3W~ any ~ 3 \':4 ~ I , JN VE9 En•Ce - ~OJxF"iPD ~''Z'~ccoc o• [A ~fiA'~-~ H~WTON •1 "AREA 2 41 u•e _ S 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. 3/19/2010 $A C`O Case # SAM-3-10-5614 CATAWBA COUNTY HEALTH DEPARTMENT Environmental Health Section 1842 sM 03/19/2010 WATER SAMPLE FIELD REPORT APPLICANT OWNER BUILDING SYSTEMS OF CATAWBA CO BUILDING Darrell Matthews SYSTEMS OF CAT CO 9310 W NC 10 HWY PO BOX 3409 Vale NC 28168 HICKORY NC 28603 8283276677 Site Address 9310 W NC 10 HWY, Vale, NC Name of Subdivision Parcel Number 266703429478 Lot Block 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: 3/19/2010 $A C~ Case # SAM-3-10-5614 CATAWBA COUNTY HEALTH DEPARTMENT V Environmental Health Section 184 2 sM 03/19/2010 WATER SAMPLE TEST RESULTS APPLICANT OWNER BUILDING SYSTEMS OF CATAWBA CO BUILDING Darrell Matthews SYSTEMS OF CAT CO 9310 W NC 10 HWY PO BOX 3409 Vale NC 28168 HICKORY NC 28603 8283276677 Site Address 9310 W NC 10 HWY, Vale, NC Name of Subdivision Parcel Number 266703429478 Lot Block 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 ELATech Initials Date/ Time Received Date/ Time Completed 3/19/2010 Iv1~.R, 19. 2010,, FRI 09. ? i. Bui 1ding -)7SteMs FA..: 1\1 928376678 P. 001 To : F A X Company; _ Fax number: C/6,S -2.2 Building Systems of Catawba County Inc. ' From:_2C General Contractors Date: PO Box 3409 Hickory NC 28603 ; Regarding: l/~GG G ~ Ph 828 327 6677 Fax 828 327 6678 www.bui[ding-system.com i Number of Pages (including cover): BUTL,ER` ! Comments: C N ~ tC 9a h4~.R; 19, "~1~10,'FFI 09,1 Btailding S•stems Fr. No. 8283`'76678 P, 00 Catawba County Public Health Department Prlrit Fprm Environmental Health Division l ® Request for Water Sample su Sample Requested By: BUILDING SYSTEMS Home Phone: State Road Number/Name: 9310 W NC HWY 10 Business Phone: 828-327-6677 _ i _ Mailing Address: MA17HEWS PROPERTIESO F VALE, LLC 972 TANGLE DRIVE HICKORY, NC 28602 Name of Subdivision f Lot Section/Block Phase: Specific Directions. TAKE HWY 10 WEST TO THE INTERSECTION OF OLD LENOIR ROAD ON THE RIGHT. THE PROPERTY IS LOCATED TO THE [RIGHTOF HWY 10 AND OLD LENOIR ROAD. i Sample Requested for: r Bacteriological r inorganic Chemical Other Type of Well: F X-'. Drilled Bored F- Dug Other Is the well on this same property? Yes No is the power on and Is an outside spigot available to collect a sample? F' Yes r; No Has the well been tested before? r yes 7; No Results: Does the plumbing come out the top of the well through a sanitary well seal? Yes r No Does the well ever become cloudy or has there ever been a problem with taste and/or order? F' Yes (X No If yes, explain . Does the well top extend six (6) inches above the ground or well slab? (R; Yes F-, No The well Is In: F7 Front JX Rear r: Left Side r-! 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 hatntless Catawba County, Its elected offlcials, employees and agents for any property damage that may occur. Date: 03-19-2010 ; Signature of Owner or Agent DARRELL R BROWN (For Office Use Only) Please Contact: i Between 8 am and 9am Phone: Fee Date Paid Receipt # i Initial