HomeMy WebLinkAboutIMPV-06-2016-073064.TIF s.6 • CATAWBA COUNTY Case N IMPV-06-2016-073064
. �Q Public Health Department Subdivision
G0,�ifQd< Environmental Health Division PIN# 368901092292
PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 LOT# 2
/ 2 a
NAME ON PERMIT: *COBBLE CREEK CUSTOM HOMES LLC, 1658 MAGGIE ST, CATAWBA NC
28609
Site Address: 1082 SHILOH RD, CATAWBA NC 28609
Property Size: Square Feet:49,658.40 Acres:1.140
Directions: Hwy 16 to IGA, Left onto Buffalo Shoals Rd, Right onto Shiloh Rd, Lots will be on the Right
Owner/Authorized Representative Acknowledgement of Permit Receipt
S11 certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
property described above.
soAs the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service EH PR-05-2016-23866 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: 06/02/2016 Q� --
Owner/Authorized Representative Signature . ,t z-��
Date re7
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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ehpeimit 06/03/2016 13:15 Page 3 of 3