HomeMy WebLinkAboutWELL-05-2016-072612.TIF 45,A _ie CATAWVBA COUNTY Case# WELL-05-2016-072612
.7 Al �, Public Health Department Subdivision Dane Meadows
2 '.0.'1 ,tis, Environmental Health Division PINK 367804501015
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�84Z M PO Box 389, 100-A Southwest Blvd,Newton,NC 28658
LOT# 13 & PT 12
NAME ON PERMIT: HIGH POINT BUILDERS LLC, 5171 ELLEN AV, ARCHDALE NC 27263
Site Address: 4500 S NC 16 HWY, MAIDEN NC 28650
Property Size: Square Feet:31,798.80 Acres:.730
Directions: Hwy 16 S, corner of Pine Leaf Dr
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-OS-2016-23858 by the following method(s):
Received in Person
7Eacsimile Transmittal (Return form with signature required)
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: 05/20/2016
Owner/Authorized Representative Signature
Date
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit trans itted b L�A� old 1 1 IS (name of person ending permit) /��
Signature � f lam/ * Date/Time`� �� 1!- I ( 'W
Method: Fax mail US Mail Other
Owner's reque t to se'nndnby the above in icated method ac.A .cei transmittal in lieu of signature
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