HomeMy WebLinkAboutEXSY-06-2022-173214.TIF i ,
' 'l'- . CATAWBA COUNTY Case# EXSY-06-2022-173214
[5U
,y. Public Health Department Subdivision ROCK BARN CLUB OF GOLF
4. Environmental Health Division PIN# 375304802596
PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 30
l; Su
Site Address: 2835 PALMER DR NE, CONOVER NC 28613
Name on Permit: RAY COMBS
Property Size: Acres 0.63
Directions: Rock Barn Rd,turn right on Lyle Creek the 2nd right onto Palmer Dr on the corner of Palmer and Snead Ct NE
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
the 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-03-2022-40411,by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
7 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: 06/09/2022
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)
SignatureE Date/Time U I) u/ )
Method: Fax V 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 yaiPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
(�ag co m bs y3e 1 ah 0 .ftrA
ehpennit 06/09/2022 08:20