HomeMy WebLinkAboutEXSY-03-2022-167638.TIF C,ses EXSY-03-202I-167638
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Lv ' Public Health Department mar PIN/ 373207592950
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Site Address: 1505 EASTOVER DR NW,CONOVER NC 28813
Name on Permf: CHARLES GREENE,JR
Name on Permit: SHANE GREENE
Property Site: Acres 3.11
Directions: Hwy Old 70 to Herman Sipa Rd,2 miles on L to Eastover Dr,2nd Drive on L
Owner/Authorized Representative Acknowledgement of Permit Receipt
6 1 certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
iC As the property owner or authorized representative,I have received the above referenced
permits)as requested in the application for service RBPR-02-2022-40222,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
1( 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 Caroiira Laws and Ryles for Sewage Treatment and Disposal Systems(1SA NCAC 18A.1900),
and/or Well Construction Standards(1SA 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:03/16/2022
Owner/Authorized Representative Signal C
-'7 Date ,s-S-2a-
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/Time 514)))
Method: _Paz _/ Email _US Mall Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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