HomeMy WebLinkAboutAUTH-08-2022-176969.TIF 0 i .f a CATAIVBA COUNTY ,
,�j�i(.....i.in' Public health Department Subdivision THE RETREAT
ti,1,_,,'et Environmental Health Division PINt 460701398091
��� PO Box 389,25 Government Drive,Newton,NC 28658 1,OT8 12
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BiteAddrees: 3687 LAKE BLUFF DR,SHERRILLS FORD NC 28673
Neme on Permit: 'NIBLOCK HOMES LLC
Property Size: Acres 0,98
Direationr Hwy 150 to Lanting Bridge RD,Left Sherrlls Ford RD,Left on Beatty Right Lake Bluff
Owner/Authorized Representative Acknowledgement of Permit Receipt
C ti
ertify 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
rC pennit(s)as requested In the application for service RUPR-04-2022-40829,by the following method(s):
_ Received in Person
Facsimile Transmittal(Return form with signature required)
I' Electronic Image Transmittal/E-mail (Return receipt required)
�` � s 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),
andlor 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:08/03/2022 toiry:717/44
Owner/Authorized Representative Signatur
Date ,YI rI2 2-
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by _ _(name of person sending permit)
Signature_ __ ___ fl
Date/Time D I z)z,z—
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 youPlease ttake a few momentts tto complette cur custtomer service survey att
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411pennn 08/032021 10:00