HomeMy WebLinkAboutIMPV-05-2022-170593.TIF CATA%%B COI '+Tl
!., Public Health Drpanment Subdi+tsion LITTLE PROPERTIES LLC
Y< I Emlronmental Health pnrsron PINu 368702662956
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\ j Po Box 189.25 Uovcmmeni Ilene,`c%�1un,NC 28658 Lt)TP TRACT 4
Site Address: 5556 LITTLE PKW', SHERRILLS FORD NC 28673 i
Name on Permit: CHRISTOPHER KITCHENS
Property Size: Acres 5.13
Directions: Newton-south Hwy-16 Left on Mt Beulah Rd, Left at Gate little parkway Gate Code(10177)Site on the nght
Owner/Authorized Representative Acknowledgement of Permit Receipt
ecertify that I am the owner or authorized agent(o++ncr's authorization required)representing the o++ner of
operty dcscrihed ago c.
As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service RBPR-07-2021-38279,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
_4__ 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(I5A NCAC I8A.1900),
and/or Well Construction Standards(I SA 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 __ %
Date lt'J /rdy 202G
' Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmit;cd by . __ Maine r/per on sending perrrriu
Signature_ IC, Date/Time J 41))
i
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 yoiPtease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey,com/s/EHCusttomerService
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