HomeMy WebLinkAboutIMPV-01-2016-068380.TIF s3• • CATAWBA COUNTY Case# 030_,
7' 4' i Public Health Department Subdivision HERON COVE
< to 0 Nc„�. Environmental Health Division PIN# 461901187984
a„. PO Box 389, 100-A Southwest 13Ivd,Newton.NC 28658 LOT# 11
1• .2 w
NAME ON PERMIT: TRISTAN TAYLOR, 137 BOLTON ST, BOSTON MA 02127
Site Address: 8188 ENERGY LN, CATAWBA NC 28609
Property Size: Square Feet:32,234.40 Aeres:0.74
Directions: Sherrills Ford Rd to Molly's Backbone Rd/ right on Energy Lane/ lot on left
Owner/Authorized Representative Acknowledgement of Permit Receipt
ertify that I am the owner or authorized agent (owner's authorization required) representing the owner of the
property described above.
OA-
As the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service RBPR-11-2015-22747 by the following method(s):
\Xeceived in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/ E-mail (Return receipt required)
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: 01/20/2016 /1
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Owner/Authorized Representative Signatur- 0"
Date 7/9q/0,2k-to,
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name ofperson 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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ehpermit 01/20/2016 08:37 Page 4 of4