HomeMy WebLinkAboutIMPV-05-2016-072620.TIF sgA t:+:i ,- CATAWBA COUNTY
f , Flublic Health Department Subdivision
6 ; ®q 4 Environmental Health Division P1N4 269802670590
uu" PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 LOT#
1842/
NAME ON PERMIT: CHARLES SHANKLES, 3453 PLATEAU RD, NEWTON NC 28658
Site Address: 3455 PLATEAU RD, NEWTON NC 28658
Property Size: Square Feet: 321,037.20 Acres:7.37
Directions: Hwy 10 West, Propst Cross Road, Left on Plateau Rd about 1 mile, House is on the Right beside Fred T
Foard High School.
Owner/Authorized Representative Acknowledgement of Permit Receipt
I 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-04-2016-23694 by the following method(s):
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: 05/20/2016
-- Owner/Authorized Representative Signature
Date
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted b}) all. m I $ A at (name of person sending permit �/
Signature t_i�1I1 t tit, Date/Timer JO
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 05/20/2016 12:41 Page 3 of 3