HomeMy WebLinkAboutIMPV-07-2016-074999.TIF Aq CATAWBA COUNTY• •
,�P L Public Health Department Subdivision
d ��1 ;; Environmental Health Division PIN# 371520812982
' PO Box 389, 100-A Southwest Blvd,Newton. NC 28658 LOT# 3 & PT 4
/842 :N
NAME ON PERMIT: RODERICK HARGROVE, 4131 1ST STREET PL NW, HICKORY NC 28601
Site Address: 1550 46TH AV NE, HICKORY NC 28601
Property Size: Square Feet: 167,270.40 Acres:3.84
Directions: go north on McDonald Prkway, turn right onto 16th St PL NE, turn left onto 46th AV NE lot will be on your left.
Owner/Authorized Representative Acknowledgement of Permit Receipt
Y /�/�
Y/P'I certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
property described above.
&WAs the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service RBPR-12-2014-20500 by the following method(s):
''-/Received in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/ E-mail (Return receipt required)
J of As the property owner or authorized representative I have reviewed and understand the specific conditions
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: 07/27/2016
rc3Owner/Authorized Representative Signature \ i�> 0
---3- Date --7(Z7/1t/10 ( /1
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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ehpennit 07/27/2016 08:24