HomeMy WebLinkAboutIMPV-02-2016-068834.TIF �gA •• CATAWBACOUNTY Case Ii
Q' G Public Health Department Subdivision SLT ENTERPRISES LLC
P
Q . ®f,�; Environmental Health Division PIN# 377112856042
PO Box 389. 100-A Southwest Blvd,Newton.NC 28658 LOTII 1A
/,842 mm
NAME ON PERMIT: WILBERT MULLINS, 19035 SHETLAND RD, APPLE VALLEY CA 92308
Site Address: 4882 HOT ROD RD, CATAWBA NC 28609
Property Size: Square Feet:589,802.40 Acres:13.54
Directions: 10E/ left Hot Rod Rd/ property on right
Owner/Authorized Representative Acknowledgement of Permit Receipt
prop1 certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
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 RBPR-12-2015-22928 by the following method(s):
N/ Received 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: 02/03/2016
>Owner/Authorized Representative Signature e I
Date 3-7 - R- (3\Lo
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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ehpennit 02/03/2016 11:00 Page 4 of 4