HomeMy WebLinkAboutIMPV-09-2022-181553.TIF i
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��t Public Health Department Subdivision
_ Environmental ltcahh Division PINK 375014349007
tPO Box 389,25 Government Drive,Newton,NC 28658 I.OP! 21-28
Site Address: 1102& 1104 MANOR ST,CONOVER NC 28613
Name on Permit: 'SW PROPERTIES NC LLC
Property Size: Acres 0.81
Directions: Take Hwy 10 East from Hwy 16 Manor is located between Mt Olive Church and Little 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.
Y ,S As the property owner or authorized representative, I have received the above referenced '
I, permit(s)as requested in the application for service RBPR-03-2022-40468,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
.5) 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(I5A NCAC 18A.1900),
and/or Well Construction Standards(15A NCAC 2C .0I00), shall apply to the issuance of this permit and
the construction of the wastewater system and/or water supply well permitted.
Permit Issue Date:09/30/2022
Owner/Authorized Representative Signature -�- j/(,)
Date l� _7._
Z.
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature--4L/ __Date/Time iD'1J))
Method: Fax V 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 act
http://www.surveymonkey.com/s/EHCusttomerService
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