HomeMy WebLinkAboutAUTH-03-2018-097257.TIF fig: a CATAWBA COUNTY Case#
Public Health Department Subdivision DOCKSIDE VIEW PH 4
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Newton,NC 28658
P
Q ylEnvironmental Health Division
PO Box 389,100-A Southwest Blvd, 460701268499
LOT#IN# 29
NAME ON PERMIT: *BURNETT HOME BUILDERS, 7887 MOUNTAIN SHORE DR, SHERRILLS FORD
NC 28673
Site Address: 3687 BURTON ST, SHERRILLS FORD NC 28673
Property Size: Square Feet:22,651.20 Acres:0.52
Directions: 150 East Left Mt Pleasant right dockside right on burton lot on left
Owner/Authorized Representative Acknowledgement of Permit Receipt
?4,0certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
• 0 As the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service RBPR-01-2018-28244,by the following method(s):
Received in Person
_ Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
9rAs 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: 03/27/2018 /�
Owner/Authorized Representative Signaturg,......-271
Date `'fRTr! f J/ -f g
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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et,pe,mil 03/282018 11:05