HomeMy WebLinkAboutAUTH-08-2022-177654.TIF 4"�,� llri CATAWBACOUVTt
,t, t Public Health DepartmentSubdivision
ti.� �s Environmental Health Division PINS 376112972371
� PO Box 389,25 Government Drive,Newton,NC 28658 LOUw
Site Address; 2371 OLD ISLAND FORD RD,CLAREMONT NC 28610
Name on Permit; 'K.M.TARKOVICH CONSTRUCTION INC.
Property Size: Acres 58,77
Directions: Claremont to Old Catawba RD, Right on JB RD, Right on Old Island Ford Rd, Property behind Barn on Left top
of hill
Owner/Authorized Representative Acknowledgement of Permit Receipt
1 certify that I am the owner or authorized agent owner's au
8 ( authorization required)representing the owner of
tthhe�property described above.
As the property owner or authorized representative,I have received the above referenced
permit(s) requested
p s( )as in the application for service RBPR-05-2022-41041,by the following tttethod(s):
___ Received in Person
4 Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
f lee
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 ISA.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 wafer supply well permitted.
Permit Issue Date:08/12/2022
Owner/Authorized Representative Signature �-:
Date�� I�� K t?*,►r. > . in¢+4.••,.ea
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature e Date/Time 'SiIi r J?Z
Method: Fax - Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
We wants no hear from yotPlease take a sew momentts tto complette our custtomer service survey an
http://wv.rw.sunreymonkey.com/s/EHCusttomerService
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