HomeMy WebLinkAboutIMPV-07-2016-074419.TIF /C,A CATAWBA COUNTY
° Public Health Department Subdivision LAKEPOINTE NORTH
4 1a Environmental Health Division PINY/ 462801372436
\7 PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 LOTH 5
NAME ON PERMIT: JAMES BARTLEY, 108 PENWOOD DR, CARY NC 27511
' Site Address: 2572 PENNGATE DR, SHERRILLS FORD NC 28673
Property Size: Square Fect:48,787.20 Acres:1.12
Directions: Sherrills Ford Rd to elementary school I Island Point Rd left Pennegate/ right lot#5 /25472 Pennegate Dr
Owner/Authorized Representative Acknowledgement of Permit Receipt
4 I certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
I �
property described above.
((1% As the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service RBPR-09-2015-22260 by the following method(s):
_ Received in Person
Facsimile Transmittal (Return form with signature required)
V 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: 07/12/2016
Owner/Authorized Representative Signature *\-� our.-\.---1
Date 7-15-2_0 (C,
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature • LL Date/Time 7/1311s
I 1
•
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 07/13/2016 12:32