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�y `� CATAWBA COUNTY Case# IMPV-02-2016-069212
tiPublic Health Department Subdivision
Q . i. Environmental Health Division PIN# 368901477961
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PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 LOT# 4
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NAME ON PERMIT: JOSEPH LASALA, 116 KILBORNE,
Site Address: 5499 THREE SISTERS LN, CATAWBA NC 28609
Property Size: Square Feet:43,560.00 Acres:1.00
Directions: Travel North on Sherrils Ford Rd, Turn South on Buffalo Shoals Rd, 1/4 mile, Turn Left into Battle Run
Community, Right onto Muskey Dr, At the end of the road.
Owner/Authorized Representative Acknowledgement of Permit Receipt
�z I certify that 1 am the owner or authorized agent(owner's authorization required)representing the owner of the
property described above.
Z. As the property owner or authorized representative. I have received the above referenced permit(s) as
requested in the application for service EHPR-10-2015-22523 , by the following method(s):
JReceived in Person
Facsimile Transmittal (Return form with signature required)
_ Electronic Image Transmittal/ E-mail (Return receipt required)
J 575"Z-As the property owner or authorized representative I have reviewed and understand the specific conditions
1` 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: 02/15/2016
i '
Owner/Authorized Representative Signature , 9
I .6.,
Date 9/X/
(72A-(72A-,7 J X
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/Time
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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