HomeMy WebLinkAboutWELL-06-2022-174415.TIF >� � CA7: W:t\('bt V•I'
i, Puhl.:I Lalth 1 1'pa�meat
p I ti uhJi�rs�an
• Environmental health Division
Plea 461704733329
IK)Buy.1Kv,25 Government Ikicr,Newton.NC 'MOH/yti:�'. !O'I'N 1
Site Address: 3954 CEDAR WOOD TR. TERRELL NC 28682
Name on Permit: NED WILLIAMS
Property Size: Acres 0.66
Directions: head on 150,turn on Kiser Island Rd.Across from the light at Marshall Steam Station,3rd Left onto Cedar
Wood Trail
Owner/Authorized Representative Acknowledgement of Permit Receipt
/G''
r I rertilj that I ant the Owner or authorized agent(owner's authorization required)representing the owner of
the property described ahos e.
Z� �
As the property owner or authorized representative. I have received the above referenced
permits)as requested in the application for service RBPR-05-2022-41156, by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
J Electronic Image Transmittal/E-mail (Return receipt required)
L'/
___As the property owner or authorized representative I have reviewed and understand the specific conditions
, ol'the permit issued, and further understand that all applicable regulatory requirements specified
p d under the
North Carolina Laws and Rules for Sewage Treatment and Disposal Systems(15A NCAC i 8A.1900),
anti/or Well Construction Standards(I5A NCAC 2C.0100), shall apply to the issuance o1'this permit and
the construction of the wastewater system andFor water supply \yell permitted.
Permit Issue Date:06/22/2022
/crOwner/'Authorized Representative Signature ," i c'2t-d
- Date_____A ✓Or..- -7'
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted h} (nwne n/•person sending
pernrit')
Signatu __re e — --- t'1)ail✓
Method: Fax 'TiDate�Time
Email US Mail _ Other
Oss ner's request to send by the above indicated method of transmittal in lieu of signature
We wantt tto hear from yotelease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
ne(I1 Il<<i„ss �:''<5n o• r. 4.11
1 r
,0.2 2.22 16 22