HomeMy WebLinkAboutWELL-04-2022-170116.TIF �Y1r CATAW BA COUNTY • ___
S41• t: Public Health Department Subdivision GABRIELACRES
,R l s' Environmental Health Division PINK 461602573467
.� PO Box 389,25 Government Drive,Newton,NC 28658 LOIN 3&4
VEX/ so
Site Address: 4551 KISER ISLAND RD,TERRELL NC 28682
Name on Permit: *ROBY, INC.,ANDREW
Property Size: Acres 0.78
Directions: Highway 150E right on Kiser Island Rd lot on right
Owner/Authorized Representative Acknowledgement of Permit Receipt
KImo'- I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
KCI--- As the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service RBPR-03-2022-40528,by the following method(s):
_ Received in Person
Facsimile Transmittal(Return form with signature required)
1 Electronic Image Transmittal/E-mail (Return receipt required)
kY_I-- 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(ISA 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:04/25/2022
1
Owner/Authorized Representative SignatureJ LA-)'11Miv
f 1
Date S / 1-3 / ., -
-- \i,1�i l<I-v,Iel I a6a•wnir��6/y'
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Ej Date/Time 5(1/1>
Method: Fax `r 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/EHCusttomer5ervice
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l 1617)IJd Ser.ice Center,Raleigh.NC27699.161/
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