HomeMy WebLinkAboutIMPV-03-2016-070279.TIF :Y • CATAWBA COUNTY tis l G Public Health Department Subdivision BROOKRIDGE
< j-' ^ Environmental Health Division PIN# 364808789953
\' PO Box 389, 100-A SoutMJest Blvd,'Newton,NC 28658 LOT# 74&75
18.2 s.
NAME ON PERMIT: KEY BUILDERS, INC., 2125 MAIN ST E, LINCOLNTON NC 28092
Site Address: 2407 DELLINGER DR, NEWTON NC 28658
Property Size: Square Feet: 31,363.20 Acres:.720
Directions: St James Ch Rd/turl left onto Dellinger/propert on left
Owner/Authorized Representative Acknowledgement of Permit Receipt
/ � JI certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
perty described above.
As the property owner or authorized representative. I have received the above referenced permit(s) as
`4- re ested in the application for service RBPR-11-2015-22768 by the following method(s):
Received in Person
I
I 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 e permit issued, and further understand that all applicable regulatory requirements specified under the North
C rolina 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: 03/21/2016
s n
.- Owner/Authorized Representative Signature
Date 3-atI-11,
T Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending perrnil)
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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