HomeMy WebLinkAboutIMPV-10-2015-065445.TIF F > CATAWBA COUNTY Case 4 IMPV-10-201 i-065445
.�.: �� Public Health Department Subdivision Fred McCall Unrec
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,;ojt��� En.v:ronincnuJ Health Division PMT 460604809782
� ! PO Box 359, 100-A Southwest Blvd,Norton.NC 28658 1.0"I_� 1
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NAME ON PERMIT: LEAH DEVLIN, 8117 NETHERLANDS DR, RALEIGH NC 27606
Site Address: 7941 KEISTLERS STORE RD, SHERRILLS FORD NC 28673
Property Size: Square Feet 21,344.40 Acres:49
Directions: Hwy 150, right Slanting Bridge, right Keistlers Store Rd, on the right
Owner/Authorized Representative Acknowledgement of Permit Receipt •
rcertify that I am the owner or authorized agent (owner's authorization required) representing the owner of the
` ��ppr�pe�roperty described above.
�} u"!As the property owner or authorized representative. I have received the above referenced permit(s) as
requested in the application for service EHPR-04-2015-21219 , by the followiatcdoet14 R(s):
Received in Person 1 tJ ��16
Facsimile Transmittal (Return form with signature required) Hi TH
{jv
Electronic Image Transmittal/ E-mail (Return receipt required) p-WAD"' L At
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: 10/08/2015
Owner/Authorized Representative SignaturC4 CIO, e1'n
Date g//al /6
(( Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted IS 010 (zr�rnh (name of person sending permit)�y��
Signature I�k',.�-I} .4_,L ) )L. .t _ Date/Time OM — 1)2Co
Method: Fax VEmailUS Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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