HomeMy WebLinkAboutAUTH-07-2022-176052.TIF 4la• CATAWIIA COUNTY Case a AUTII-07-2022-176052
.C'FALL Public I health Department Subdivision
<, � Environmental l health Division
V.ZNMI376303143288
W 110 Dos 399,25 Government Drive.Newton.NC 29659 I,O'(p
Site Address: 4574 ROCK BARN RD,CLAREMONT NC 28610
Name on Permit: LEAH BROWN
Property Size: Acres 1.45
Directions: 1-40 to Rock Barn Rd,go over creek past Hall Dairy Rd, house on the right with brick sundial in front yard
���,.y�s7, Owner/Authorized Representative Acknowledgement of Permit Receipt
'r 1 certify that I ant the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
44)As the property owner or authorized representative, I have received the above referenced
permits)as requested in the application for service EHPR-07-2022-41698, by the following method(s):
_ Received in Person
f 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 (ISA NCAC 18A-1900),
and/or Well Construction Standards(15A NCAC 2C.0100), shall apply to the issuance of this pennit and
the construction of the wastewater system and/or water supply well permitted.
Permit Issue Date: 07/20/2022
Owner/Authorized RepRepresentative Signature 4-".-/
Date 1 I aalaa _ .
Documentalion of 1'ermit(s)'1-ransmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending per mil)
Signaturej Date/'fine /'))/) 3
Method: _Fax V Email _US Mail Other
Owner's request to send by the above-indicated method or transmittal in lieu of signature -'
We wantt tto hear from yoiPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
ohpcnnin el/21Re22 211
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