HomeMy WebLinkAboutWELL-03-2018-097259.TIF 74/bAy • CATAWBA COUNTY Cases
lC�ics .).� Public I lealth Department Suhd"inion DOCKSIDE VIEW PH 4
',q4j,.mi® ,x,' Etvironmemul Health Division flak 460701268499
PO Box 389.100-A Southwest Blvd,Newton.NC 28658 1.0 re 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 Peet 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
?l.\_1 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)asasrequested in the application for service RBPR-01-2018-28244, by the following method(s):
'k/ Received in Person
Facsimile Transmittal(Return loran with signature required)
Electronic Image Transmittal/E-Inail (Return receipt required)
As the property owner or authorized representative I have reviewed and understand the specific conditions
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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(ISA NCAC ISA.1900),
and/or Well Construction Standards(ISA 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 Signature I
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Date — C1‘—'1416:77 l —(X
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name qf person sending
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
We wantt tto hear from youPlease Rake a few momentts tto complette our custtomer service survey att
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