HomeMy WebLinkAboutIMPV-05-2016-072810.TIF CATAWBA COUNTY
C' Public Health Department Subdivision
Q. a 4 Environmental Health Division PIN# 266702994220
'•4 PO Box 389. 100-A Southwest Blvd,Newton.NC 28658 LOT#
1842 :M
NAME ON PERMIT: MATTHEW STEELMON, PO BOX 1252, NEWTON NC 28658
Site Address: 3397 WELLMAN RD, VALE NC 28168
Property Size: Square Feet:434,293.20 Acres:9.97
Directions: 10W , right Rhoney Farm Rd /left Wellmon Rd /approx 1/2 on right
Owner/Authorized Representative Acknowledgement of Permit Receipt
IA I certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
N/ property described above.
J t(? As the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service RBPR-05-2016-23804 by the following method(s):
-.../ Received in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/ E-mail (Return receipt required)
MIS 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: 05/26/2016
Owner/Authorized Representative Signature iaa
J Date 6/10 (6
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/Time
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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ehpe]m it 05/26/2016 11:59 Page 3 of 3