HomeMy WebLinkAboutIMPV-05-2016-072547.TIF 0 • CATAWBA COUNTY Case# IMPV-05-2016-072547
.7:;742 <G Public Health Department Subdivision
o4r. y Environmental Health Division PIN# 269802670590
"^1R- / PO Box 389, 100-A Southwest Blvd.Newton,NC 28658 LOT#
/882 sm
NAME ON PERMIT: CHARLES SHANKLES, 3453 PLATEAU RD., NEWTON NC 28658
Site Address: 3453 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 EHPR-04-2016-23693 by the following method(s):
_ Received in Person
esimile Transmittal (Return form with signature required)
F
lectronic 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: 05/19/2016
> Owner/Authorized Representative Signature
Date
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted By _ IIS' , It (name of person sending permit)
1-1,.
Signature L�fl J 11 � • Date/Timb (o t Q Jo
Method: Fax mail US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
_` k. ®a' 1e___a --We want to hear from you. Please take a few moments to complete our customer service survey at:
http://www.surveymonkey.com/s/EHCustomerservice
ehpermit 05/20/2016 12:38 Page 3 of 3
cr