HomeMy WebLinkAboutIMPV-06-2022-173599.TIF f
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1 Public Stealth Department Subdivision l A CARPENTER ESTATE RED
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J,- Environmental Health Division PINlI 364605291275
PO Box 3S9,25 Government Drive,Ncv4on,NC 28658 LO'I l 83.86
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8Ite Address: 121 PINE TREE DR, MAIDEN NC 28650
Name on Permit: CHRIS ODOM •
Property Size: Acres 0.46
Directions: 321 to Maiden/left W Main stl right S Main Ave/left Pine Tree Dr
Owner/Authorized Representative Acknowledgement of Permit Receipt
V' "I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above, j
C.JOAs the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service RBPR-02-2022-39978,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
4 Electronic Image Transmittal/E-mail (Return receipt required)
1(gC 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:06/14/2022
Owner/Authorized Representative Signature CDcA{/r ,
—7 Date Ce f'(7/ oAA
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by_ �r (name of person sending permit)
Signature cit/ Date/Time iiiiiii___
Method: Fax V Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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