HomeMy WebLinkAboutIMPV-01-2016-068283.TIF A CATAWBACOUNTY Case# IMPV-01-2016.068283
T rr++"IIa Public Health Department Subdivision Fred McCall Unree
< ' Eneiu,!mcmal Health Division PINT 460604809594
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.r' PO Box 389: 100-A Southwest Blvd,Newton.NC 28655 LO'FN 2
NAME ON PERMIT: JANET MCCALL LIVING TRUST, 1601 HERALDRY LN, GREENSBORO NC 27455
Site Address: 7951 KEISTLERS STORE RD, SHERRILLS FORD NC 28673
Property Size: Square Fret:20,908.80 Acres:.48
Directions: Hwy 150, right Slanting Bridge, right Keistler Store Rd. property on right
Owner/Authorized Representative Acknowledgement of Permit Receipt
r"Mb I unify that I am the owner or authorized agent(owner's authorization required) representing the owner of the •
7� property described above.
, � As the property owner or authorized representative. I have received the above referenced permit(s) as
requested in the application for service EHPR-04-2015-21220 , by the following method(s):
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Received in Person L 16
/ Facsimile Transmittal (Return form with signature required) MQ�� 1
L �/ Electronic Image Transmittal/ E-mail (Return receipt required) - ,,,, ?Y
ChiN�gy. .-p1/4,' 7H
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(2As the property owner or authorized representative I have reviewed and underst illAPsvpecific 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: 01/15/2016 /
Owner/Auttho ized Representative Signature tqr ° ' I IALI � 11�
d I
Date 1 � � //O t� .. 7rl �r- LOX�
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit tran'mined by , SS L•1 I. • IIII3 (name gfperson 'en ing perrtlm�it)
Signature 1p-_IP '�,� t 1 ►b Date/Time - 0 el k3;30
Method: Fax \mail US Mail Other
0 ner's request to send by the above indicated method of transmittal in lieu of signature
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