HomeMy WebLinkAboutAUTH-3-10-5665.TIF
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MATTHEWS VETERINARY CLINIC
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9310 W NC 10 HWY, VALE, NC
1842 sM
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 property described above.
✓ As the property owner or authorized representative, I have received the above referenced permit(s)
as requested in the application for service EHPR-3-10-3009 , by the following method(s):
V" 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 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 3/22/2010
Owner/Aut orized Representative Signature
/ v
Date 2'1
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
acknowledges the conditions and statements above.