HomeMy WebLinkAboutWELL-06-2022-173341.TIF cwr� CATAWBA COUNTY
. Public Health Department Subdivision
Environmental Health Division
PINM 265703042672
PO Box 389,75 Government Drive,Newton,NC 28658 t O(q
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Stte Address: 3845 PEA RIDGE RD, LAWNDALE NC 28090
Name on Permit: 'CLINE CUSTOM BUILDERS INC
Property Size: Acres 5.53
Directions: West on 18 Exit on to Roger Hill Rd left in.6 miles turn left on to pea ridge rd in.5 miles the destination will
be on your right
Owner/Authorized Representative Acknowledgement of Permit Receipt
I certify that l am the owner or authorized agent(owner's authori7lition 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-03-2022-40536, by the following method(s):
Received in Person
�` Facsimile Transmittal (Return form with signature required)
�/ 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: 06/10/2022
Owner/Authorized/ Representative Signature
Date (q /--1Y. o-2z
411-E10.°kJ.
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature — Date/Time i //SI)
Method: Fax J 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/EHCusttomerService
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