HomeMy WebLinkAboutIMPV-06-2022-174598.TIF/ 1 '''l ___,...,..,
,S8. CATAWBA COUNTY
1� '' `11111 fII Public Health Department Subdivision LEWIS ESTATES
d 4, Environmental Health Division PIN# 368703318678 .'
PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 10
18 2 su
Site Address: 4145 SIM CHICK LN, MAIDEN NC 28650
Name on Permit: MARYANNE HOGUE
Property Size: Acres 1.26
Directions: Old Hwy 16 next to Mt Boulah Road
Owner/Authorized Representative Acknowledgement of Permit Receipt
\ I IC. I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of t
( the property described above.
As the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service EHPR-04-2022-40644,by the following method(s):
/Received in Person
Facsimile Transmittal(Return form with signature required)
Electronic Image 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(15A NCAC 18A.1900), ,;-"
and/or Well Construction Standards(15A NCAC 2C.0100), shall apply to the issuance of this permit and : Ap
the construction of the wastewater system and/or water supply well permitted.
Permit Issue Date:06/27/2022 rn
Owner/Authorized Representative Signature 0 _� W v i
�� Date 1 • 1 `J 2 0 2 C0
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/Time
Method: Fax 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 yomPlease ttake a few momentts tto complette our custtomer service survey att
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elipennit 06/28/2022 09:35 f