HomeMy WebLinkAboutAUTH-05-2015-060134.TIF 4(5A • t CATAWBA COUNTY Case N AUTH-05-2015.060134
.� G Public Health Depanment Subdivision
;41;9 0 l l Environmental Health Division PtNN 371416946711
�\ ,�^+l PU Bov 389,1011-A Southwest Blvd,Newton,NC 28658 LOIN
NAME ON PERMIT: JOSHUA XIONG, 1726 33RD AV NE, HICKORY NC 28601
Site Address: 1726 33RD AV NE, HICKORY NC 26601
Property Size: Square Feet 71,874.00 Acres 1.65
Directions: SPRINGS_RD TURN ON KOOL PARK RD, LEFT AT THE 3RD LIGHT FROM CAMPBELL SCHOO. HOUSE
WILL BE ON THE LEFT
Owner/Authorized Representative Acknowledgement of Permit Receipt
LEI certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
ssiNproperty described above.
VAs the property owner or authorized representative, I have received the above referenced permits) as
requested in the application for service EHPR-03-2015-21057 , by the following method(s):
2eceived in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/ E-mail (Return receipt required)
v-\ As the property owner or authorized representative I have reviewed and understand the specific conditions
i
/ �of the permit issued, and further understand that all applicable regulatory requirements specified under the North
' Carolina Laws and Rules for Sewage Treatment and Disposal Systems (15A NCAC 18A .1900), and/or
Well Construction Standards (15A NCAC 2C .0100), shall apply to the issuance of this permit and the
construction of the wastewater system and/or water supply well permitted.
Permit Issue Date: 05/04/2015 g_. :
Owner/Authorized Representative Signature /
Date c5- C3 - 2O16
Documentation of Permit(s)Transmittal ✓✓
(permit transmitted by electronic or other means)
Permit transmitted by (name afperson sending permit)
Signature Date/Time
Method: Fax Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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