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CATAWBA COUNTY I~EAI,,TH DEPARTMENT wLS#~OO/-GY~1Cv
Telephone: (828) 465-8270 TDD: (828) 465-8200
'rr}2>f. ~., Opr. Prmt.~ $ys. Type Well Prmt. Replacement We11~We11 Rpr. Prmt.
Lot#
" r ~ - - Property Alddress Y~ G~XJ`
Facility: House Mobile Home Business Multi-family .Other: Pin Number U ~ c~7 - ,,
Other .Zoning Approval # o
# Bedrooms # Seats # Employees .Application Rate GPD Flow
Hot Tub or Spa yes/no Special Fixtures Basement yes/no .100% Repair ea yes/no
Basement Plumbing yes/no Water Supply: Private Well blic Semi-Public
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Type of System: Trench Bed Pump Pump/Panel anel Other
Septic Tank Size mp Tank Size ' r' cat' field: Total q e Feet DeptU. of Ston
Bed Size Tr ch Wi T t n of A renche r of T enche
Trench Length /_/ /_/_ Feet on enter Maximum ench epth Distance of Nearest Well
*DO NOT INSTALL SEPTIC WHEN WET* *WELL RECORD REQUIRED AT COMPLETION*
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Struc re ~
Clay in. ~
Soi Wetne ~
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estric. o t ~
vailab p e y / ~
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Filter Required ~
Riser required when ~
tank is more than 6 ~
inches deep. ~
**NO GUARANTEE OR WARRANTY IS IMPLIED OR GIVEN AS TO THE PERFORMANCE OR LENGTH OF TIME THIS SYSTEM
WILL FUNCTION**
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*Improvement Permit has no expiration date and is transferable, but may be revoked if site plans or intended use changes for the proposed
facility. An Authorization to Construct is valid for (5) five years from date issued and is not transferable. Well Permit valid for 5 years
provided site conditions do not change. Well location, installation, and protection must meet state and local regulations, and must be
inspected and approved by a representative of the Catawba County Health Department before any portion of the installation is put into use.
The siting of the well by the Health Department staff is to provide protection from known possible sources of contamination. No volume of
water is guaranteed at any site by th Health Department.
Permit Date ~- ` EHS _~ ~~
Owner/Agent- Septic T Installed By Date
EHS Well Installed By Well Grout Approval Date~~
Well Head Approval Date- - (~ ~ Date Sample Collected
Date of Results Results EHS
White -Office Blue -Building Inspection Operation Permit Yellow -Owner/Agent Green -Building Inspection Authorization to Construct
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