HomeMy WebLinkAboutWELL-06-2022-173570.TIF ,4011,". CATAWBA COUNTY Case a WELL:06-2022-173570
-j. Public Health Department Subdivision
. Environmental Health Division PINK 371413040183
Po Box 389,25 Government Drive,Newton NC 28658
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Site Address: 203 29TH AVE NE, HICKORY NC 28601
Name on Permit OL PARLIER&SON GRADING
Property Size: Acres 7.18
Directions: N Center St, right 29th Av NE,on left just past 2nd St NE
Owner/Authorized Representative Acknowledgement of Permit Receipt
X I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
` the property described above.
kf As the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service EHPR-05-2022-40901,by the following method(s):
Received in Person
JFacsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
1( K 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 Data:06/14/2022
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Owner/Authorized Representative Signature �� &o/Gt,vsr.✓c
Date (7(7 /e-
Z
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending plermii)
SignatureOf..
Date/Time 6 Ii 7'J)
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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chprnmt 06/15/2022 0822