HomeMy WebLinkAboutAUTH-10-2022-181682.TIF rATAWRA(:otN'rY (aseY At III 1-to-2022-1ftIMO
/ Public Health Department Subdivision SLEEPY HOLLOW
1< •I Environmental Ilcalth Division I'INH 373309057788
PO lior 389,25(ioveniment Drive,Newton,NC 28658 I U'D'a 29-32
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Site Address: 1951 SLEEPY HOLLOW DR. HICKORY NC 28601
Name on Permit: TYLER ISENHOUR
Property Size: Acres 0.55
Directions: Springs Rd, right Section House Rd, left Sleepy Hollow Dr. at end on right
Owner/Authorized Representative Acknowledgement of Permit Receipt
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I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
)(11 As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service EHPR-09-2022-42400, by the following method(s):
Received in Person
__ Facsimile Transmittal (Return form with signature required)
'/ Electronic Image Transmittal/E-mail (Return receipt required)
As the property owner or authorized representative I have reviewed and understand the specific conditions
(1 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.0100), shall apply to the issuance of this permit and
the construction of the wastewater system andior water supply well permitted.
Permit Issue Date: 10/04/2022
Owner Authorized Representative Signature 1 W
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Date 4f11QI ,111,4,
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name(lf nee,:em sending permit)
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Signature cC - Uate/Time t
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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