HomeMy WebLinkAboutWELL-03-2018-097322.TIF tasett •
�H CAPAWBA COUNTY
�� Public Health Department Subdivision DOCKSIDE VIEW PH 4
1 �(TEOV—/!' 1 Environmental Health Division YIN& 460701267475
PO Box 389. 100-A Southwest Blvd,Nc0.vmNC 28658 LUI a 30
NAME ON PERMIT: *BURNETT HOME BUILDERS, 7887 MOUNTAIN SHORE DR, SHERRILLS FORD
NC 28673
Site Address: 3693 BURTON ST, SHERRILLS FORD NC 28673
Property Size: Square Fem.22,215.60 Acres 0.51
Directions: 150 East to Left on Mt Pleasant lot on left
/)//�'� Owner/Authorized Representative Acknowledgement of Permit Receipt
< p) ,I certify that I am the Amer 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 RBPR-01-2018-28245, by the following method(s):
Received in Person
_ Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
_
'4,07 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 tinder the
North Carolina Laws and Rules for Sewage Treatment and Disposal Systems(ISA NCAC I8A.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: 03/2812016
Owner/Authorized Representative Signature/ - -
Date 54-21-1" ((
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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