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(• Environmental Health - Division of Public Health
COUNTY pmts ienffn PO Box 389—100-A South West Blvd.- Newton, North Carolina 28658
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AUTHORIZATION OF REFUND
Date: 6/24/2016
Case #: EHPR-06-2016-24022
Applicant: Elizabeth Gold
Refund Amount: 300.00
Refund Reason: AC Malfunction—Installer was able to clean out
Distribution box & correct problem. No Site Visit
Made by EH Staff.
Authorizing Signature: Jai. VV ---)
Received By Staff: 1 $h 9 1119%
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Vendor No. Date 06/24/16
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Make Payment To: � COG Voucher No(s).
Elizabeth Gold Eel�I,'z
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2205 Angle Dr UQ 7►�
Conover NC 28613 1842
ATTACHMENT
Prepared by: Katherine Harris
Description Amount
AC Malfunction-Problem corrected. No Site visit made by EH. 300.00
Sub-Total $ 300.00
Food Tax
Sales Tax
Total $ 300.00
UI I r' I IIntl .x I rW i::,!In'1 IIxIIInGVll''lhxvn1, II �Ir .In
r' I III 1!F ! 1'4.1411 rl, ll-ti 1 tI�.•.,. III IIlIi' I Accounting I]�t
� il Faod1 ,III. ICostice ter, "I'::', 6bj`ect1,1< ;Projecting IIIIIIII�IIkIIILIAIImount,' 4IIIIhIn1 iIGIIIilllidird IUse;A'o' y ?I 1,,
110 4580200 663000
Total -
The undersigned hereby certifies that the goods or services specified above have been received
or performed. Payment has not been previously authorized and this expenditure is a proper
charge to the appropriation indicated. The above charge is certified to you for payment.
(SIGNATURE-APPROPRIATE OFFICIAL)
,)A- CATAWBA COUNTY
CO; �� ooA souTHwesT BLVD
'' NEWTON,NORTH CAROLINA 28658 RECEIPT
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�P�� PHONE: 828.465.8399
U W� � �I�jsvp Friday, June 24, 2016
1842 zM www.catawbacountync.gov
PAYOR:
Gold, Elizabeth
PAYMENTS
TRANSACTION NUMBER: "CRC-703027-24-06-2016
PAYMENT DATE : 06/24/2016
PAYMENT TYPE: DV
INVOICE NUMBER FEE NAME FEE AMOUNT
06-16-329053 Authorization to Construct (Repair) ($300.00)
Fee
TOTAL PAYMENTS : (5300.00)
EI-I PR-06-2016-24022
CASE TYPE: Environmental Health Plan Review WORK CLASS: Septic Malfunction
SITE ADDRESS: 2205 ANGLE DR,CONOVER NC 28613
Owner ELIZABETH GOLD, 2205 ANGLE DR, CONOVER NC 28613
H:8284618499
** NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 06/24/2016 16:20 Page 1 of 1