HomeMy WebLinkAboutWELL-05-2016-072609.TIF sn CATAWBA COUNTY Case tl WELL-05-2016-072609
h' tQ G Public Health Department Subdivision Dane Meadows
6�'-$—?�� Environmental Health Division PINK 367702593688 mc
\'1� PO Box 389, 100-A Southwest Blvd.Newton.NC 28658 LO'P# 8
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NAME ON PERMIT: HIGH POINT BUILDERS LLC, 5171 ELLEN AV, ARCHDALE NC 27263
Site Address: 4534 S NC 16 HWY, MAIDEN NC 28650
Property Size: Square Feet: 20,473.20 Acres:.470
Directions: NC 16 S, 5th lot on left past 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.
ri As the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service EHPR-05-2016-23862 by the following method(s):
Received in Person
csimile 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)
yiYC�4
Permit transmitted b �,���1 1 � (name of se ding �(,ermit)
Signature ' P' 1 Date/Tim !�0 I -CO
Method: Fax t-mail US Mail Other
Owner's requ st to send by the abo e indicated method of transmittal in lieu of signature
nipit n e Gla►-cons
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