HomeMy WebLinkAboutIMPV-05-2022-172401.TIF 0 s e CATAWBA COUNTY
h .). Public Health Department Subdivision CRESCENT LAND AND TIMBE
E . Environmental Health Division
ilNa 461901483563
PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 153
Site Address: 1425 LANGDON RD, SHERRILLS FORD NC 28673
Name on Permit SHAWN KIRKLEY
Property Size: Acres 0.91
Directions: Hwy 150 to Sherrills Ford Rd, R on Mollys Backbone, R on Azalea Rd, I on Dog Leg, L on Roundstone,
property on left
Owner/Authorized Representative Acknowledgement of Permit Receipt
X. Nccnify that I am the owner or authorized agent(owner's authorization required)representing the owner of
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thhe property described above.
)<As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service RBPR-05-2022-40923,by the following method(s):
Received in Person
/ Facsimile Transmittal (Return form with signature required)
11 Electronic Image Transmittal/E-mail (Return receipt required)
tiAs 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: 05/26/2022 �/
Owner/Authorized Representative Signature %:tl �l/
.4--- Date D 7
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (nwne of person sending permit)
_hl _____
Signature Date/Time t
)
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 att
http://www.surveymonkey.com/s/EHCusttomerServiceC ,,
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