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_MbAddress: 4190 HERTER RD.LINCOLNTON NC 28092
Kazuo on Pa u& TYLE ARDREY
Prorwar tuna Acres 29.38
Dwamm let driveway on the left past driveway on Right of 4169 Herter RD i
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Owner/Authorized Representative Acknowledgement of Permit Receipt
I catify that I am the owner or authorized agent(owner's authorization required)representing the owner of
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the property described above.
II II As the property owner or authorized representative,I have received the above referenced
ennit(s)es requested in the application for service RBPR-05-2022-40961,by the following method(s):
' _ Received in Person
Facsimile Transmittal(Return form with signature required)
Nar Electronic Image Transmittal/E-mail (Return receipt required) •
As the property owner or authorized representative I have reviewed and understand the specific conditions
1( f 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(ISA NCAC 18A.1900),
and/or Well Construction Standards(ISA NCAC 2C.0100), shall apply to the issuance of this perriit and
the construction of the wastewater system o water supply well permitted.
Permit Issue Date:0624/2022
Owner/Authorized Representative Si 1 't'
Date 1 kZ(Z-t--
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of sending permit)
Signature ()f Date/lime elkal»
Method: Fax Email US Mall Other
Owner's request to send by the above indicated method of tranamiusi in lien of signature '"
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