HomeMy WebLinkAboutAUTH-04-2022-170293.TIF x -
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•�1(�, Public Health Department Subdivision —
ii • Environmental Health Division PINK 366703215422
PO Box 389,25 Government Drive,Newton,NC 28658 LOT#l:ilt
Sits Address: 4161 BUFFALO SHOALS RD, MAIDEN NC 28650
N.Iiia on Poratia :ANDREW PARKER
Property Size: Acres 4.19
Directions: Hwy 321 N bus/Maiden Hwy, Right Springs RD,Left onto Buffalo Shoals,lot on left
Owner/Authorized Representative Acknowledgement of Permit Receipt
lS frtify that I am the owner or authorized agent(owner's authorization required)representing the owner ofterty described above.s the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service RBPR-02-2022-40219,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
J Electronic Image Transmittal/E-mail (Return receipt required)
xAs the properly 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 systun and/or wstcr supply well pci,iiitti,d.
Permit Issue Date:04/27/2022 77
Owner/Authori Rep sentative Signature ;i/;D7�/ir U 4rx..-------
`'- i Date 7 3
------------------------
Documentation of Permit(s)Transmittal
(permit tr&tEs!iiI(icd ty ClictC4L:LC-or O.r.:i-L::;.'i`., •
Permit transmitted by (name of person sending permit)
Signature Cif ./ Date/Times/)f)
Method: Fax v Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
We waiiit tit?hear trGril yotPiease i2ake a i ew n omentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/ENCusttomerServIce
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