HomeMy WebLinkAboutWELL-08-2022-177099.TIF r=� CATAWBA COUNTY Case a WELL-08-2022-177U'19
!' ---ii Public Health Depanment Subdivision
<r�. 1 Environmental Health Division PIN 373215539365
No'J� PO 13ox 389.25 Government Drive,Newton.NC 28658 LOT#
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Site Address: 111 TRACK PL SW, CONOVER NC 28613
Name on Permit: CLARK KNOLLMEYER
Property Size: Acres 6.77
Directions: exit 130 off 1-40 Conover.Proceed towards Hickory turn left onto Track PL,croos tracks, stay straight
Owner/Authorized Representative Acknowledgement of Permit Receipt
ertily that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
gthe property owner or authorized representative. I have received the above referenced
permit(s)as requested in the application for service EHPR-07-2022-41766, by the following inethod(s):
_ Received in Person
t! Facsimile Transmittal(Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
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6s 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(I5A NCAC 18A.1900),
and/or Well Construction Standards (I5A 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:08/04/2022 4‘24D
Owner/Authorized Representative Signature ___"
Date Er'/t -O22
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (twine of person sending permit)
Signature _ �� Date/Tim3,I) I))
Method: Fax Ni 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 yoWlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
C (ark—KA° II metier— Ct) 9 111.4tV . Gin
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Catawba County Environmental Health
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Parcel: 373215539365, 111 TRACK PL SW 1 ire=6Qft
CONOVER, 28613
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0712 :v..2