HomeMy WebLinkAboutWELL-09-2022-179650.TIF CATA,WBA COUNT',' Case N WELL 09-2022-179G50
.e lit Public I Icalrtncnt Subdivision
EnvironmentalthDepa Health Division PIN# 460803137925
PO Box 389.25 Government Drive,Newton,NC 28658 LOU 1
, W
Site Address: 2889 MT PLEASANT RD, SHERRILLS FORD NC 28673
Name on Permit: GEORGE AND CARMEN VERHOEST
Property Size: Acres 6.18
Directions: NC 10 E,right onto Murrays Mill Rd,left onto Sherrills Ford Rd,right onto Mount Pleasant Rd,property on the
right
/ Owner/Authorized Representative Acknowledgement of Permit Receipt
`V I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
1 V As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service ENPR-08-2022-42112,by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
7 Electronic Image Transmittal/E-mail (Return receipt required)
GiAs 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 I8A.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:09/07/2022
Owner/Authorized Representative Signature _/--...--"--'
Date -I[ 151 021--
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signatureq-' Date/Time I/ti))
Method: Fax V'Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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