HomeMy WebLinkAboutIMPV-10-2019-123022.tif � 4, be CATAWBA COUNTY Case IMI'V-111-2019-123022
a -le Public Health Department Subdivision
Environmental Health Division PINII 360803224087
PO Box 389,25 Government Drive,Newton,NC 28658 LOT#
Site Address: 4759 GRACE CHURCH RD, NEWTON NC 28658
Name on Permit: MARIBEL SERNA
Property Size: Acres 5.32
Directions: West NC 10, turn left on Hickory Lincolnton Hwy.turn right on Grace Church Rd, lot on left
Owner/Authorized Representative Acknowledgement of Permit Receipt
Y11 certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
he 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-09-2019-32748,by the following method(s):
�eceived in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
*Sets 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: 10/04/2019 Owner/Authorized Representative Signature a i I ask__
1___
Date q- ,9]-3-3
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 yoiPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
eltpo m it 10/08/2019 14:03