HomeMy WebLinkAboutAUTH-08-2022-177857.TIF `. CATAWBA COUNTY
1,:tr ,z Public Health Department Subdivision
Environmental HealthGovernment Division PIN# 367704745780
f Zvi � ,Newton,NC 28658 Drive LOT#
Site Address: 3814 ANDERSON MOUNTAIN RD, MAIDEN NC 28650
Name on Permit: MAUREEN PERRY
Property Size: Acres 5.77
Directions: 16 S, Left on Anderson Mt Rd, House on Left
Owner/Authorized Representative Acknowledgement of Permit Receipt
XI certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
KffAs the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service RBPR-05-2022-41124,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
7- Electronic Image Transmittal/E-mail (Return receipt required)
plieAs 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),
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 water supply well permitted.
Permit Issue Date: 08/16/2022
caner/Aut rized Representative Signature I; ,Pany
Date g
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/Time
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 yaPlease stake a few momentts tto complette our custtomer service survey aft
http://www.surveymonkey.com/s/EHCusttomerService
e Ip I,,,it 08/16n022 16:06 /1 --/C—