HomeMy WebLinkAboutIMPV-07-2022-176589.TIF 4.4,`= r CATAIIBA('Ol'IcfY
' Public'l alth tkry nment
a' Envinxunentat Het Ith Divemon gut*I"''"I"r SHERWOOD SHORES
' I'INti 4(31902763474
if PO Box MY,25 Government Drive,Newum.Ni' 2865g
fat s* Llrl'+ 7
Sae Address: 1885 SHERWOOD CT, SHERRILLS FORD NC 28673
Name on Permit: PATRICII)LOPEZ
Property Size: Acres 0;i8
Directions: Hwy 150 Right on Sherrtlls Ford RD, Right on Molly Backbone, Right on Azalea, Right on Dog Leg, Lett on
SherwooI CT
Owner/Authorized Representative Acknowledgement of Permit Receipt
v.
I certify that I am t)c owner or authorized agent toclner's authorization required)rep;escnting the ulv'ner of
the proper() described a Nn'e.
.__ As the property owner or authorized representative. I have received the above referenced
pernit(s)as requested in the application Ibr service RBPR-I0-2021-39154, by the feil lowing method(s):
_._ Received in Person
Facsimile "Transmittal (Return titrm with signature required)
4 klectroni,: Image Transmittal!E-mail (Return receipt requited)
As the property owner or authorized representative I have reviewed and understand the specific conditions
ofthe permit issued, a set further understand that all applicable regulatory
6 y requirements specified under the
North Carolina Laws and Rules for Sewage Treat, ent and Disposal Systems(15A NCAC ISA.1900),
and/or Well Construction Standards(15A NCA .2C.0100), shall apply to the issuance of this permit and
the construction of the .wastewater system andfor titer supply well permitted.
// /
Permit Issue Date:07/2 3/2022 l : ! ' ,
Owner/Authorized�cp escntatise Signature ' -' /fir/',r 6w 0 /.,it/::
Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit I'unsutitted by (nwut'n/"person sending permit)
i el
Signalure l Cr �f
Met sod: Fats J Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
We wantt t:o hear from yotPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EH CusttomerService
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