HomeMy WebLinkAboutWELL-08-2022-178810.TIF r
e=. CATAWBA COUNTY Case# WELL-08-2022-178810
1Public Health Department Subdivision
_4111
Environmental Health Division PIN# 369804828581
PO Box 389,25 Government Drive,Newton,NC 28658 LOT# UNNUMBERED LOT
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Site Address: 3097 MATTIE WADE RD, SHERRILLS FORD NC 28673
Name on Permit: JERRY LYNN
Property Size: Acres 0.48
Directions: Murrays Mill Rd, left onto Sherrills Ford Rd, right onto Hopewell Ch, right onto Mattie Wade Rd
Owner/Authorized Representative Acknowledgement of Permit Receipt
_I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
XAs the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service EHPR-06-2022-41380, by the following method(s):
Received in Person
_ Facsimile Transmittal (Return form with signature required)
•f Electronic Image Transmittal/E-mail (Return receipt required)
As the property owner or authorized representative I have reviewed and understand the specific conditions
r 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: 08/29/2022
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 C. Date/Time A Z
Method: Fax `r Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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WPDT Report
Area of Interest (AOI) Information
Area : 3,134,508.7 ft2
Sep 1 2022 8:12:25 Eastern Daylight Time
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3097 Mattie Wade
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