HomeMy WebLinkAboutWELL-07-2022-175631.TIF •
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s 4, • CATAWBA COUNTY
-r. Public Health Department Subdivision
1 Environmental Health Division PfNt! 366603440934
PC)Box 389,25 Government Drive,Newton,NC 28658 t.OTft
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Site Address: 3399 E MAIDEN RD, MAIDEN NC 28650
Name on Permit: VIRGINIA DELLINGER
Property Size: Acres 23.04
Directions: S NC Hwy 16, Right onto Buffalo Shoals RD, Left onto E Maiden RD, Property on Right before Honest Bob RD
Owner/Authorized Representative Acknowledgement of Permit Receipt
X _ I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
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 RBPR-06-2022-41394, by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
JElectronic 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
the construction of the wastewater system and/or water supply well permitted.
Permit Issue Date: 07/13/2022
Owner/Authorized Representative Signature
Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person se ding permit)
Signature Date/Time
111)1
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 yor,Please ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
d. deivi i er 'b of e. Ern
RP
chpcnnit 07/14,2022 07:09