HomeMy WebLinkAboutEXSY-10-2022-182707.TIF ellriN ('AI.tWBA COUNTY V Case II
yam' a. Public Health Department Subdivision
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Environmental Health Division I'INtJ 372419517897
PO Box 389.25(;mernmen!Drive,Nevoon,N(' 28658 I.(i fN 33
Site Address: 3102 KOOL PARK RD NE 33, HICKORY NC 28601
Name on Permit: 3102 KOOL PARK ROAD NE TRUST
Property Size: Acres 12.4
Directions: Springs Rd, West on Kook Park Rd 1 mile,Homesite is on the right
Owner/Authorized Representative Acknowledgement of Permit Receipt
certily that I am the owner or authorized agent(orxner's authorisation required(representing the owner of
the property described ahoxe.
:'-As the property owner or authorized representative. I have received the above referenced
permit(s)as requested in the application for service RIBI'R-06-2022-41511, by the following method(~):
Received in Person
Facsimile Transmittal (Return ornt with signature required)
1 Electronic Image Transmittal/ -1-mail (Return receipt required)
l As the property owner or authorized rt presentative 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(I5A 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: 10/20/2022
1
Frederick Akker, Manager
Owner.Authorized Representative Signature
Date 10/27/22
Documentation of l'ermit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person permit!
Signature Date/ Iime V j��1,�
Method: Fax "4 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 yotPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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