HomeMy WebLinkAboutWELL-05-2022-171102.TIF o=4, CATAWBA COUNTY _ __-_ . ____ -- — - —.
!! �-�` Public Health Department Subdivision THAD AND HAROLD GABRIEI
R`i.,,,J. Environmental Health Division PINK 461703116639
PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 19&ADJ
Site Address: 4215 CASCADE ST,TERRELL NC 28682
Name on Permit NICK WATTS
Property Size: Acres 0.63
Directions: Right onto Sherrills Ford Rd,right onto Hob Ln.Take a left at the end and its the 4th lot on the 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
K—
the property described above.
X_ As the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service RBPR-11-2021-39300, by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
41 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(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: 05/10/2022
Owner/Authorized Representative Signature
Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature C. Date/Time lit) I ))
Method: Fax I Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature --
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Parcel: 461703116639, 4215 CASCADE ST 1 in=40t
TERRELL, 28682
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Copyright 2021 Catawba County NC
05/10/2022
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