HomeMy WebLinkAboutAUTH-02-2016-069232.TIF : ,v; CATAWBA COUNTY Case# •,•— •
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i Public Health Department Subdivision
,\�\itinr, Environmental Health Division PINN 266801286507
PO Box 389, 100-A Southwest Blvd.Newton.NC 28658 LOT#
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NAME ON PERMIT: CLYDE & KAREN BROWN, 1308 SW 39TH ST, HICKORY NC 28602
Site Address: 8940 JACOB FORK RIVER RD,VALE NC 28168
Property Size: Square Feet:865,101.60 Acres:19.86
Directions: Old Shelby Rd/approx 5 miles/right Jacob Fork River Rd
Owner/Authorized Representative Acknowledgement of Permit Receipt
Cal certify that lam the owner or authorized agent(owner's authorization required)representing the owner of the
property described above.
( ` CO As the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service RBPR-05-2015.21536 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
bfthe 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: 02/16/2016
�� Owner/Authorized Representative Signatur- _/ / I. Ap.,4,a
Date ',yt/�6' /
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Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by i ■i , ' ' 111.... In name ofperson 'ending permit
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Signature `` ,,) _ milt Date/Time _f , / 0 �Li. J�
Method: Fax mail US Mail Other
Own is request to send by he apove indicated method of transmittal in lieu of signature
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