HomeMy WebLinkAboutIMPV-11-2022-183595.TIF Nov/11/2022 10:29:55 AM Claremont Family Med. 828-615-7692 1/3
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�t it> CATAWBACOUNTY` I CaseN IMPV•l1•2022•I$3393
f ,,A Palls Health Department I Subdivision
,; , , 4ti Environmental HealthDlvlslo�t • PINS 375411662741
' \ , . PO Box 389,25 Government)rive,Newton,NC 28638 LOTH 1
SlteAndress: 5336 N NC 16 HWY,CLAREMONTNC 26810
Name on Permit: CODY WILLIAMt;
Property stae: Acres 1 I
otreetrens; first grave Rd aftrr NC Hwy.16 anbd Oxford School Rd Intersection if heading north on NC Hwy 16 ;
Owner/Authorized Representative Ackn wledgentent of Permit Receipt
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KI cat*that l am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
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K0,1As the property owner 03 representative,I have repeived the above referenced
permit(s)as requested in the 4pplication for service EHPR4I O•Z02Z-4Z376,by the following method(s): •
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_ Received in Person
_ Facsimile Transmittal(Return form with signature qulred)
i Electronic Image Transmittal/E-mail (Return recei required) ;
1( tlL As the property owner oi.authorized representative I have re sewed and understand the specific conditions
of the permit issued, and 1brther understand that all applicable re ulatory requirements specified under the
North Carolina Laws and Rules for Sewage Treatment and D posal Systems(I SA NCAC I8A.1000),
and/or Well Construction Standards(15AN.CAC 2C.0100), stall apply to the Issuance of this permit and
the construction of the wastewater system and/or water supply we I permitted,
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Permit Issue Date: 11/04/2022
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Owner/Authorized Representative Signature
Date 1((11 (i-
DueumentatioflOfFermlj "fl'an5rnKtai •
(permit transmitted by electronic or other means)
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Permtt'transtr�itted•by ,(name ofpersan sending permit)
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Signature 1 e Date/Time $9 `,I23
Method:, Fax J Email US Mail Other •
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Owner's requests to send by'the above indicated method of transmittal in lieu of signature
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• We wantftto hear from yruPleaasettalte a few momet+is tto complete our custtomer service survey aft
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• http://www.surveymonitey.com/s/E11CusttomerServIce
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• ebpemdl t 104/2022 o8:40
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