HomeMy WebLinkAboutIMPV-07-2022-174956.TIF ...
CATAWBA COUNTy
Public Health DemYnc.0 Subdivision i MT EIEUiAN EST
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0 Environmental Health Division PINli .•389701393060
.141.7'-,......PO Box 389,25 Government Drive,Newton,NC 28658 tarts 9 *
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Sibs Address: . 3411 KINGS AVE,SHERRILLS'FORD NC 28873
Name on Permit EILEEN CONLEY
Property Size: Acres 0.47
otreetlens: 18 Business'to Mt Beulah R to Little Mountain R kings eve
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• Owitei/Attthor4e4 Representative Acknowledgement of Permit Receipt
. ....L., [pettily that II am,the owner,or Authorized agent(owner's authorization required)representing the owner of
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the property described above.
14s the property owner or authorized representative,I have received the above referenced • . - ,
ierntit(s)earequeStedin the application for service FilIPR444022-€10728,zby the fOliniiing.melbc4(s :
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Received in Person
i Facsimile Transmittal(Return form with signature required)
Electronic Image'Transmittal?E-mail (Return receipt required)
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• -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), 2 •
and/or Well Construction Standards(ISA NCAC 2C t0109),:shall apply to the issuance of this permit and
theconstnictionef the wastewater system and/or water supply well permitted.
Permilissue Date:07/01/2022
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Owner/Authorized Representative Signature
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' Date 74/0/7 0 2 2-- ' ...
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Documentation of Permit(s)Transmittal:
(permit transmitted by electronic or other means)
Permit transmitted by... (name 1i i
of person sending perm10
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Signature ,,,,.„,,, Date/tribl, ,7.. 1• . ,r
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Method: Fax ALEmall VS Mail Other
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Owner's request to send by ihe above indicated method of transmittal in lieu of signature
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We wank to hear from yotPlease take a few inoirientts tto complete our custtomer service sttrOey at •
httprj/www.surveymenkey.com/s/EFICusftonterService
e ‘ti-no Kotiocoltotaa . .
Memnit 07/0i/2025 1015 ,
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