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i.`4). CATAWBA COUNTY Cesc# IMPV-05-2022-170579
1� 1 n�,j Public Health Department Subdivision ASTORIA
3� �et Environmental Health Division PINS 471001285180
PO Box 389,25 Government Drive,Newton,NC 28658till * LOT# 35
Site Address: 1316 ASTORIA PKWY, CATAWBA NC 28609
Name on Permit GLEN NONEMAKER
Property Ste: Acres 0.6
Directions: Sherrills Ford Rd, left Hopewell Church Rd,right Regal Blvd,left Astoria, lot on right
Owner/Authorized Representative Acknowledgement of Permit Receipt
I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
(rthe property described above.
X '`As the property owner or authorized representative,I have received the above referenced •
rmit(s)as requested in the application for service EHPR-02-2022-40096,by the following method(s):
_ Received in Person
Facsimile Transmittal(Return form with signature required)
7 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
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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:05/03/2022
Owner/Authorized Representative Signature • O71 ..--N--
Date 051000ZZ-
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person
LLsending permit)
Signature efi
Date/Time J114),
Method: Fax v Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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