HomeMy WebLinkAboutWELL-08-2022-177752.TIF r t
=�� CATAWBA COUNTY
r(.....).�. ,z Public Health Department Subdivision
d Environmental HealthGovernment DivisionDrive,
PIN# 375302873534
`C YNewton,NC 28G58mi LOT#I2 ,w
Site Address: 2826 COMMUNITY RD, CLAREMONT NC 28610
Name on Permit: CLAYTON HOMES#81 (UNLICENSED GC-BILLING ACCT)
Property Size: Acres 0.95
Directions: Hwy 16 N; Right Shook RD, Left Community, lot on Left
Owner/Authorized Representative Acknowledgement of Permit Receipt
\K _I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service RBPR-07-2022-41613,by the following method(s):
Received in Person
/ Facsimile Transmittal (Return form with signature required)
J Electronic 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(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: 08/15/2022
Owner/Authorized Representative Signature
Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature (1)L Date/TimeSILL
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 yoiPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
itILAQ
cIiprimir 08/18/2022 09:17