HomeMy WebLinkAboutEXSY-10-2021-160107.TIF rt, S2FAWBATOU WV Casrtt GXSY-10-2021-160107
0/.+-h Public Health Department Subdivision
'` ) Environmental Health Division PINa 363814435170
�\ Pt)Box 389,25 Govemment Drive,Newton,NC 28658 I Orafo w
Sits Address: 2949 SIGMON DAIRY RD,NEWTON NC 28658
Name on Permit: ROBERT DIXON
Property Size: Acres 1.67
Directions: Hwy 10 W, left on Sigmon Dairy Rd,go 2.5 miles and the home is on the right, long gravel drive
Owner/Authorized Representative Acknowledgement of Permit Receipt
/�I certil� that 1 am the u++ner ur authorizd agent lu++ner's authuri�ation required)representing the o++ner ut'
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the property described above.
As the property owner or authorized representative, I hate received the above referenced
permit(s)as requested in the application for service RUPR-10-2021-39077, bythe methods :
q Pp following ( )
Received in Person
f_ 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: 10/29/2021
Owner/Authorized Rei ntative Signature.
-7 Date 7Lih—
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (uwne of peryun sending permit)
Signature Date/Time _ht2,
Method: Fax f 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 yotPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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