HomeMy WebLinkAboutIMPV-09-2022-181172.TIF \C.• CA\TAIVBA COUNTY r
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,.1.� Public Health Department Sutxlivisiun
log • Environmental Health Division PINK 368702869549
PO Box 189,25 Government Drive,Newton,NC I8658 LOTH 3
Sit.Addr.ss: 3639 MT BEULAH RD,SHERRILLS FORD NC 28673
Nam.on Permit: 'LEMON BOWL RENOVATIONS LLC
Property Six.: Acres 1.06
Directions: Right off of Little Mountain Rd onto Mt Beulah Rd.4th lot on right after Lineberger Rd.
Owner/Authorized Representative Acknowledgement of Permit Receipt
)(1Wil I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
(the property described above.
X1'(\L.As the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service RBPR-07-2022-41545,by the following method(s):
Received in Person
_ Facsimile Transmittal(Return form with signature required)
f Electronic Image Transmittal/E-mail (Return receipt required)
Pi Asthe 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 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:09/27/2022
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Owner/Authorized Representative Signature "Aka-6,-,AAI
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7 Date � 1 �2-�
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
SignatureqC Date/Time 9130/))
Method: Fax " Email US Mail Other
Owner's request to send by the above Indicated method of transmittal in lieu of signature
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