HomeMy WebLinkAboutWELL-06-2022-174085.TIF ('ATAWBA COUNTY
-I.ri Public health Department SubJn isb n
Q .Fin Environmental health Division PIN# 375302857819
9iit PO Box 389.25 Government Drive,Nctivkm,NC 28b58 1.014
sits Address: 4255 WEEPING PINE DR. CLAREMONT NC 28610
Name on Permit: JOSEPH SPEAKS
Property Size: Acres 0 97
Directions: Right off of Community Rd onto Weeping Pine Dr 4th lot on right
Owner/Authorized Representative Acknowledgement of Permit Receipt
.111/110
certify that I am the owner or authorized agent(owner's authorisation required)representing the owner of
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the property.described above.
As the property owner or authorized representative, I have received the above referenced
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permit(s)as requested in the application for service RBPR-04-2022-40891, by the following method(s):
Received in Person
j Facsimile Transmittal (Return form with signature required)
J Electronic Image"Transmittal' E-mail (Return receipt required)
As the property owner or authorized representative I have reviewed and understand the specific conditions
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of thepermit issued, and further understand that all applicable regulatory re requirements specified under the
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North Carolina Laws and Rules for Sewage Treatment and Disposal Systems (I5A NCAC 18A.1900),
and/or Well Construction Standards (I5A 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: 06/20/2022
Owner/Authorized Representative Signature GPLer_41°_111.1. 1 '17f:72.11/1:2
—1 Date"4/11149/1212
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by __. (mime o/person sending permit)
Signature4r\ E- Date/Time 11 zsZU'),
Method: Fax 1 Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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