HomeMy WebLinkAboutWELL-07-2022-176187.TIF �4y)'F' a CATAWBA COUNTY Case# WELL-07-2022-176187
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1, Public Health Department Subdivision
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�,`.j 3 Environmental Health Division PiN# 367801252753
PO Box 389,25 Government Drive,Newton,NC 28658 L.OT# 2
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Site Address: 4166 LITTLE MOUNTAIN RD, NEWTON NC 28658
Name on Permit: ALETA AND BRIAN RAICHUK
Property Size: Acres 2.18
Directions: Hwy 16 S, left at IGA onto Buffalo Shoals Rd, left at next 4 way Intersection,2nd house on right just past
pond
Owner/Authorized Representative Acknowledgement of Permit Receipt
I certify that 1 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 EHPR-07-2022-41673,by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
V 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
the construction of the wastewater system and/or water supply well permitted.
Permit Issue Date: 07/21/2022
Owner/Authorized Representative Signature
Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Dr E
Signature Date/Ti me-')71 ✓r7
Method: Fax i 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 yoi.Please ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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Catawba County Environmental Health
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Parcel: 367801252753, 4166 LITTLE MOUNTAIN tin=5Oft
RD NEWTON, 28658
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personnel,disclaim,and shall not be held liable for any and ail damages,loss or liability,whether direct,indirect or conscaduoniiat which tarises or(nay
arise from this map/report product or the use thereof by any person or entity.
Copyright 202'1 Catawba County NC
0712112022