HomeMy WebLinkAboutIMPV-05-2022-171676.TIF + , C:TAwnA COUNTY Case 0 I M PV-05-2022-17 1676
.�. Puhtic Health Department Subdivision
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y i:nvironmcntal Health Division PIN# 376503121433
PO Box.3R9,25 Government Drive.hcwum,NC' 2865(3 LOTH 28A ,
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Site Address: 3062 SHELL HOLLAR RD, CLAREMONT NC 28610
Name on Permit: KATRINA MCCOY
Property Size: Acres 4.28
Directions: 1-40 east, take exit 132, left onto Thornburg Dr/NC-16, right onto NC-16 north, right onto Shell Holler Rd,
property on the right
Owner/Authorized Representative Acknowledgement of Permit Receipt
) certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
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k/i/As the property owner or authorized representative. I have received the above referenced
permit(s)as requested in the application for service EHPR-03-2022-10444,by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
.1 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 I8A.1900), ,
and/or Well Construction Standards (I5A 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:05/17/2022
Owner/Authorized Representative Signature Katrina McCoy
Date May 19, 2022
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name n/person sending permit)
Signature 131E". /
Date/Time 61
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Method: Fax I 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 yoiPlease ttake a few momentts tto complette our custtomer service survey aft
http://www.surveymonkey.com/s/EHCusttomerService
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