HomeMy WebLinkAboutEXSY-05-2022-172452.TIF f0`I! CAT,1WBA COUNTY Ccsc N EXSY-05-2022-172452
Public Health Department Subdivision SPRINGDALE
1 si Environmental Health Division PINt 360904501654
PO Box 389,25 Government[hive,Newton.NC 256511 LUT4I 30A
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Site Address: 2274 PALMETTO DR,NEWTON NC 28658
Name en Permit DAVID MOORE
Property Size: Acres 0.49
Directions: Hwy 10, R on Springdale Dr,R on Phoenix Dr, L on Palmetto Dr,Home is on the right
Owner/Authorized Representative Acknowledgement of Permit Receipt
rtify that I am the owner or authorized agent(owner's authorization required)representing the owner of
,/ the property described above.
Orr-As the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service RBPR-03-2022-40499,by the following method(s):
Received in Person
_ Facsimile Transmittal(Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required) _ . _.
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 1SA.1900),
and/or Well Construction Standards(ISA 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:05,27/2022
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Owner/Authorized Representative Signature .._�.L� , __
Date t?( 3/a b ,1-.
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by Tw (name of person sending permit)
Signature Date/Time 7I)t )45)
Method: Fax 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 yo.Please ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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