HomeMy WebLinkAboutAUTH-02-2016-069249.TIF r0• • CATAWBA COUNTY CaSe it AUTH-02-2016-069249
,I Public Health Department Subdivision BUMGARNER GARDENS
< 5 Environmental Health Division I'INII 373306494994
`'�' PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 1.0'I'N 15 & 16
NAME ON PERMIT: THOMAS SEFCIK, 4692 WILBURN DR, CONOVER NC 28613
Site Address: 4692 WILBURN DR, CONOVER NC 28613
Property Size: Square Feel: 121,968,00 Acres:2.8
Directions: North on County Home Rd/right on Allen Lane/right on Wilburn
Owner/Authorized Representative Acknowledgement of Permit Receipt
( I certify that I am the owner or authorized agent (owner's authorization required) representing the owner of the
roperty described above.
X • As the property owner or authorized representative, I have received the above referenced permit(s)as
equcsted in the application for service RBPR-02-2016-23129 by the following method(s):
_ Received in Person
Facsimile Transmittal (Return form with signature required)
It_
Electronic Image Transmittal/E-mail (Return receipt required)
X , As the property owner or authorized representative I have reviewed and understand the specific conditions
f 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: 02/16/2016
Owner/Authorized Representative Signature
Date 06 Or 20/1 _ Please initial at ,sign,date and return
permit receipt form by fax or email.
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted .y Al L. I ,_b ns (name of person sTA? permit
Signature_ _A. . . A, it. 1 I • Date/Time I lZ; ZO
Method: Fax -�/Cmail US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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