HomeMy WebLinkAboutAUTH-07-2022-174973.TIF 4 ^1wr GTAWaACOUr4TY ca./ AUDI-07.2022.174973
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'I a'• Pubtr Haitb Deperaams Subdrvaron 5 C HOLLAR ESTATE Heath Drossan PINY 375406285853
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PO Dos 389,23 Go au Drive.Nrwar1.NC 211658
a M LOTe PT 11
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sateAadm.: 6707 N NC 16 HWY,CLAREMONT NC 28610
Nerm ea Pantile XA'YANG
Proverb'ama: Ames 30.13
Directions: N NC 16 Hwy on left across from Shell Hollar Rd
Owner/Authorized Representative Acknowledgement of Permit Receipt
X},r. AI/certify
that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
XiAs the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service EHPR-O6-2 022-4 1 245,by the following method(s):
_ Received in Person
Facsimile Transmittal(Return form with signature required)
—7r
s/ Electronic Image Transmittal/E-mail (Return receipt required)
�)4,111_ 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 Riles for Sewage 7Yeatment and Disposal Systems(15A NCAC 18A.1900),
and/or Well Construction Standards(I5A 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:07/01/2022
$ Owner/Authorized Representative Signature
Date —7/7/22
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of personsending permit)
Signature
�j Date/Time !7 13 j))
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 yoaPlease crake a few mornentts tto complette our custtomer service survey art
http://www.surveymonkey.com/s/EHCusttorrwrServke
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Yhp nul ottoman 1206
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DEPARMENT OP ENVIRONMENT AND NATURAL RESOURCES Sheet!of /
D*VLSION OP ENV1R041.LENTAL HEALTH PROPERTY ID Y 3 e•5s
0441T8 WASTEWATER SECTloN COUNTY: g4
SOILJSI'f1i EVALUATION
OWNER: Yet V for ON-SITE WASTEWATER SYSTEM �_3 r
APPLICATION DATE DATE EVALU TED �''��'�
ADDRESS'_ /0 AI - l4 /RO PERTYSIZE:: 7-ism~
PROPOSED FACILITY: ,F F PROPOSED aFsi FLOW(.1949): 3
LOCATION OF SIT , SAfr'i4 PROPERTY RECORDED:, —
"WATERSUPI'LY:.$"Private 0 Public 8201011 0 Spring 0 Other _
EVALUATION METHOD: 0 Auger Boring Rini U Cut -
TYPE OF WASItWATER: i'Seuage 0 Inaustrisl Process 0 Mixed
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DESalr oN D.rnAL 93:$4 REPAIR SYSTEM[ OTHER FACTORS(.1946):
Aw11sbleSpxce C.1945) 4-7 SITE CLASSIFICATION(.1948): ►P 6.,Sysftto
7 s) d 3-2 EVALUATED BY: t ✓C^S
. OTHER(S)PRESENT:
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