HomeMy WebLinkAboutAUTH-08-2022-177803.TIF AVIV CATAWBA COUNTY ,
��' Cox s AU'I'1 I•08•2022.1 TT1103
Vi•� �' Public Rath Department 5ubdo'stun RALPH N DRUM
.,pt 7 7• fnuaanental health r)iv,Kuw� PIN* 460701078459
4 PO Box 384,25 Government Drive,New oz,.bte 28(08 LU'I'k 6
trli'Site Address: 3553 TEE ST, SHERRILLS FORD NC 28673
Name on Permit: WILLIAM LAZARUS
Property size. Acres 048
Directions; Hwy 150 E, left MI Pleasant Rd,left Tee St,
Owner/Authorized Representative Acknowledgement of I'crrnit Receipt
Xe_I cent].) that I am the ow ncr or authorized agent(owner's authorization required)representing the owner ul
the property described above
X14As the property owner or authorized representative. I have received the abot e referenced
permit(s)as requested in the application for service EIIPR-07_2022-41611, by the following method(s);
Received in Person
Facsimile Transmittal (Return form with signature required)
lectronie Image Transmittal/ E-mail (Return receipt required)
' , 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 (8A.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 car water supply well permitted.
Permit Issue Date:08/15/2022
Owner'Authori,ed Representative Signature t1/4)- R-
47,,,,,,..
Date e— 2 1— 2—
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by _ ('tuure r,/tpe•rson.%dndin,1>er•mit)
r
Signature4i Date/Time_- . %!2 z
Method: Fax /Entail US ;Mail Other
Owner's request In send by the above indicated method of transmittal in lieu of signature
We wantt tto hear from youPlease ttake a few momentts tto complette our custtomer service survey att
http://www,su rveymonkey.corn/s/EHCusttomer5ervice
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