HomeMy WebLinkAboutWELL-05-2016-072611.TIF .4.16' - CATAWBA COUNTY Case# WELL-05-2016-072611
T pP Public Health Department Subdivision Dane Meadows
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Q '^�'^• ? " Environmental Health Division PIN#
\"�Y� PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 LOT# 11
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NAME ON PERMIT: HIGH POINT BUILDERS LLC, 5171 ELLEN AV, ARCHDALE NC 27263
Site Address: 3284 PINE LEAF DR, MAIDEN NC 28650
Property Size: Square Feet:28,749.60 Acres:.660
Directions: NC 16 S, 2nd lot on left past Pine Leaf Dr
Owner/Authorized Representative Acknowledgement of Permit Receipt
I certify that 1 am the owner or authorized agent(owner's authorization required) representing the owner of the
property described above.
7C As the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service EHPR-05-2016-23863 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 byy \ Np�\1L_J/�llJ�tl -S (name ofperso sending permit)
Signature) „.l `�V Date/Tim I�@ J I ; 00
Method: Fax mail US Mail Other
•
Owner's request to send b the above indicated method of transmittal in lieu of signature
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(*penn it 05/20/2016 11:55 Page 2 of 2