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Site Address: 3980 HOKE ST,CLAREMONT NC 28610
Name on Permit: TIM BERGHOFF
Property Size: Acres 0.78
Directions: From Balls Creek Rd, turn onto Hoke St, lot is down the road near the end on the right
Owner/Authorized Representative Acknowledgement of Permit Receipt
jr! I certify. that I am thy saner or authorized agent(owner's atnhori/,typo required)representing the owner or
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the property described above.
VAs the property owner or authorized representative. I have received the above referenced
permit(s)as requested in the application Ibr service EHPR-08-2022-4211,1, by the following method(s):
Received in Person
jFacsimile Transmittal (Return form with signature required)
._ Electronic Image'1•ransmittal/E-mail (Return receipt required)
1 (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(ISA NCA(' I8A.1900),
and/or Well Construction Standards(15A NCA(•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: 10/21/2022
Owner/Authorized Representative Signature ;
Date /////a)
Documentation of Permit(s)'Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (mum,rr/person se•nrlror,r,hrrnrill
Signature
Date`Time /0 )6/,,)
Method: Fax 1 Email (IS Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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