HomeMy WebLinkAboutIMPV-07-2016-074368.TIF v,A CATA\VBA COUNTY
��'^'d Public Health Department Subdivision MOZON LITTLE HEIRS
< s 1 t Environmental Health Division . PIN# 460604814060
PO Box 389, 100-A Southwest Blvd, Newton,NC 286 58 LO"tN 3
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NAME ON PERMIT: CHRISTOPHER PEARCE, 13219 PONTCHATRAIN AV, CHARLOTTE NC 28273
Site Address: 7819 LUCY LN, SHERRILLS FORD NC 28673
Property Size: Square Feet: 20,908.80 Acres:0.48
Directions: Hwy 150 to Lake Norman, turn right on Slanting Bridge Rd, turn left on Keistler Storwe RD turn right on Lucy
LN, lot on left.
Owner/Authorized Representative Acknowledgement of Permit Receipt
IiiI certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
property described above.
kiAs the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service RBPR-06-2015-21818 by the following method(s):
'1Received in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/ E-mail (Return receipt required)
95-L.)
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: 07/11/2016 1
AIP 4 li 1
> Owner/Authorized Representative Signature , .- I, , ge..
Date 7/1 'J/I(P
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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ehpcnnit 07/11/2016 11:32