HomeMy WebLinkAboutWELL-04-2018-098440.TIF NSA CAIAVBA COUN"I'Y Case N WELL-04-2018-098440
.F'//1 tat ,7 Public Health Department Subdivision
C t Environmental Health Division PIN# 269803406496
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PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 LOT#
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NAME ON PERMIT: BRUCE BERRY, 5912 LEIL RD, HICKORY NC 28602-7199
SiteAddress: STONY BROOK CIR, NEWTON NC 28658
Property Size: Square Feet:155,073.60 Acres:3.56
Directions: NC Hwy 10 west to Plateau Rd, turn left pass Fred T Foard School, go about 2 1/4 miles and turn right on
Rock Creek Dr, go to end of road, on right
Owner/Authorized Representative Acknowledgement of Permit Receipt
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 EIIPR-04-2018-28804, by the following Inethod(s):
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 (ISA NCAC 18A.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: 04/19/2018
Owner/Authorized Representative Signature
Date L - Zit - I0
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
We wantt tto hear from yowlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EliCusttomerService
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Parcel: 269803406496, STONY BROOK CIR 1 in=40ft
NEWTON, 28658
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Copyright 2014 Catawba County NC
04/19/2018