HomeMy WebLinkAboutAUTH-04-2016-071386.TIF .t)A CATAWBACOUNTY Case# AUTH-04-2016-071386
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,F `I , Public Health Department Subdivision DUAN ACRES
j ipl0 s Environmental Health Division PIN# 364920708843
' PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 LOT# 5
/842 s,
NAME ON PERMIT: ANA MARIE RODRIGUEZ, 2241 BELMAR ST, NEWTON NC 28658
Site Address: 2241 BELMAR ST, NEWTON NC 28658
Property Size: Square Feet: 13,503.60 Acres:0.31
Directions: 321, Left on Prison Camp Rd, Left St James Church Rd, Right onto Jenkins Printing Dr, left onto Belmar St,
2nd house on the Left.
Owner/Authorized Representative Acknowledgement of Permit Receipt
Pi R I certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
property described above.
•I I t 111 As the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service EHPR-04-2016-23616 by the following method(s):
Q t N Q_jeceived in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/ E-mail (Return receipt required)
' Y ' As the property owner or authorized representative I have reviewed and understand the specific conditions
9 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: 04/19/2016
( I
Owner/Authorized Representative Signature X O\ Mari Q ,�pCJ �l 9d e-7--
Date 140 ja0l,6
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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