HomeMy WebLinkAboutAUTH-06-2022-174090.TIF Case M AUrtl-06-2022-t74090
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Environmental Health Div....-.
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PO Box IH ,25 Go.crnmcnl Drixc,Newton,NC 28658
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Site Address: 5011 WOODFIELD DR, HICKORY NC 28602
Name on Permit: JEFFERY AND JACLYN SMITH
Property Size: Acres 0 51
Directions: turn onto Pittstown from Zion Ch Rd,make a nght on Sail then a left on Woodfield
Owner/Authorized Representative Acknowledgement of Permit Receipt
I eertifc that I am the owner or authorized agent/owner's authorization required)representing the owner of
the properly described abo c.
X ,) S As the property owner or authorized representative, I have received the above referenced
perrnit(s)as requested in the application for service EHPR-04-2022-40850,by the following tnethod(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
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_V Electronic linage 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 (I5A 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: 06/20/2022
Owner/Authorized epresentative Signature t ‘,...,'
r Date_IA 2
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Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by _ (name of person sending permit)
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-�Signature_ Date/Time J JI.
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 yo&Please ttake a few niomentts tto cotmplette our custtomer service surveil aft
http://www.surveymonkey.com/s/INCusecireerServlce
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