HomeMy WebLinkAboutIMPV-06-2015-061663.TIF r55A CATAWBA COUNTY Case# IMPV-06-20 1 5-06 1 663
U�t . Public Health Department Subdivision
l 1 0`r .; Environmental Health Division PIN# 367603336865
-ahPO Box 389. 100-A Southwest Blvd,Newton.NC 28658 1,0'1# TR B
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NAME ON PERMIT: DAVID ELLIS, 6716 LOVE POINT RD, DENVER NC 28037
Site Address:. 4945 ANDERSON MOUNTAIN RD, MAIDEN NC 28650
Property Size: Square Feet 713,948.40 Acres 16.39
Directions: E Maiden Rd, Anderson Mountain Rd, property 1/2 ile on right
Owner/Authorized Representative Acknowledgement of Permit Receipt
/ I certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
property described above.
x. As the property owner or authorized representative. I have received the above referenced permit(s) as
\ requested in tthe application for service EHPR-05-2015-21590
,/ by the following method(s):
\/ Received in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
• jj,‘ As the property owner or authorized representative I have reviewed and understand the specific conditions
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: 06/12/2015 0 ^
Owner/Authorized Representative Signature _ CS f/3--„,_,,c,;,4,, O n,
Date /5 f l c
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person 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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