HomeMy WebLinkAboutIMPV-11-2022-183633.TIF y,' CATAWBA COUNTY Case# IMPV-11-2022-183633
Public Health Department n
U .). Subdivision EMERALD ISLES UNRECORE
d '1 Environmental Health Division PIN 369607698278
PO Box 389,25 Government Drive,Newton,NC 28658
LOT#
Site Address: 6714 EMERALD ISLE DR, SHERRILLS FORD NC 28673
Name on Permit MATTHEW COFFEY
Property Size: Acres 0.5
Directions: E NC 150 Hwy, left Mt Pleasant Rd, right Emerald Isle Dr. house lot on left
Owner/Authorized Representative Acknowledgement of Permit Receipt
X —I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
iAs the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service EHPR-03-2021-36953,by the following method(s):
Received in Person
_ Facsimile Transmittal (Return form with signature required)
,1 Electronic Image Transmittal/E-mail (Return receipt required)
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(15A 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 and/or water supply well permitted.
Permit Issue Date: 11/04/2022
Owner/Authorized Representative Signature
'.--- Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
idSignature Date/Time ! $�z�-
LI
Method: Fax .J 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 att
http://www.surveymonkey.com/s/EHCusttomerService
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otipero,it 11/04/2022 13:14
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'; EVALUATED BY: MARA •�f ..
'SYslall TYP€(0 PPBPS _ : PPBPS OTHERS)PRESENT: I
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SIN LTAR 035 1 0.35
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COMAFNTS:
• 'SOIL/SITE EVALUATION owe_2_*l?i
•(Continuattow Skeet)
PROPERTY ID 0: 369607696271 '
DATE OF EVALUATION:
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COUNTY:_CATAWBA_
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