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AMIIII"' CATAWBA COUNTY Case# AUTH-05-2020-132766
y�' -i-li y Public Health Department Subdivision THAD AND HAROLD GABRIEI
4 -, • Environmental Health Division PINH 461703420069
likr[zi PO Box 389,25 Government Drive,Newton,NC 28658 LOTS 42
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Site Address: 8410 SLATE ST,TERRELL NC 28682
Name on Permit: MARSHA COLE
Property Size: Acres 0.64
Directions: Hwy 150 E,right Sherrills Ford Rd,right Flat Rock Rd,left Slate St, in cul de sac
Owner/Authorized Representative Acknowledgement of Permit Receipt
,kcertify that I am the owner or authorized agent(owner's authorization required)representing the owner of
// the property described above.
160As the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service EHPR-03-2020-34181,by the following method(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(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:05119/2020
---_ Owner/Authorized Representative Signature kl a i11/ (—
Date Q
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by fi n 'Sr64 (name of person sending permit)
Signature Date/Time 5 ( :r iL4 V�
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Method: Fax V 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 ye/Please ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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ehpein+i t 03!19/2020 16:02