HomeMy WebLinkAboutAUTH-08-2022-177737.TIF yt CATAWBACOUNTV
,�T . Public Health Department
Subdivision 1MLDERNESS TRACE PH 5
,pt . �j F Environmental Health Division PIN 375504B463tI6
1 PO Box 389,25 Government Drive,Newton,NC 21658 I.OTM 157
Slte Address: 3080 MEDICINE BOW,CLAREMONT NC 28810
Name on Parrett: 'CMH HOMES,INC./OBA OAKWOOD HOMES#712(NEWTON)
Property$iae: Acres 046
Directions: Oxford School Rd/Rest Home Rd/Wilderness Trace/Left Great Divide/right Medicine Bow/across from
New Spirit Road
�
Owner/Authorized Representative Acknowledgement of Permit Receipt
� 31 certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
9' As the property owner or authorized representative,I have received the above referenced
permits)as requested in the application for service RBPR-07-2022-41603,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
ii'79 P 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(I5A NCAC ISA.I900),
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:08/15/2022
Owner/Authorized Representative Signatur Si natur 4 49eic
Date k( ' Z e_
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature _ jg.71
Date/Time /1'J2 lMethod: Fax Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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'ip""° 05'I02022 11:00 fitilt