HomeMy WebLinkAboutEXSY-11-2019-124802.TIF 4,
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t• : e CATAIVBA COUNTY Case#
t II Public Health Department IiXSY-I I-2019-t24802
Subdivision CRESCENT LAND AND TIMBE
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p, Environmental health Division
PO Box 389,25 Government Drive,Newton,NC 28658 MI 461601076471
LUDO 15
Site Address: 8193 DRAKE CT, SHERRILLS FORD NC 28673
Name on Permit: MICHAEL BRANTLEY
Property Size: Acres 0.71
Directions: Slanting bridge rd turn on Drena,turn on wellborn,turn on Drake t.
Owner/Authorized Representative Acknowledgement of Permit Receipt
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\f I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
t ie property described above.
If As the property owner or authorized representative, I have received the above referenced
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permit(s)as requested in the application for service RIDPR-05-2019-31903,by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required) ,
f Electronic Image Transmittal/E-mail (Return receipt required)
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As the property owner or authorized representative I have reviewed and understand the specific conditions
fthe 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 I SA.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: 11/13/2019
Owner/ thorized R(epr�esentative Signatur
Date 1) '�
—_--
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Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by _ �__ (name of person sending permit)
4 Signature — — _ _ Date/Time b/t/)3
Method: Fax I 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
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