HomeMy WebLinkAboutWELL-11-2022-184664.TIF ir.v7:1 (',1'.mvHA col NT1'
rI 4.�1G Public Health Delanrnent Budd. Ilan CROSSING CREEK
s' i I:muonmcntal Ilcalth 1)1%mon I'Iha 376304747331
'%.i � PO Ho.389.25(o%enunent Dove.Vc<.tan.NC28658 LOT:: 1
Site Address: 4188 DEAL RD,CLAREMONT NC 28610
Name on Permit: APRIL PITTMAN
Property Size: Acres 0.49
Directions: 300 ft turn Right Radio Station RD, 1 mile Turn Left Hwy 321 Bus, Northwest Blvd 2 2 mi turn Right onto
Conover Blvd W, 1 mi continue 7th Ave NE,Rock Barn Rd, 139 mi turn Right I-40E, 1 5 mi exit 135.0 2 mi
Right at fork,0 1 mi Left Centennial Blvd,0.3 mi Left onto State RD, 1.2 mi Left Deal RD
Owner/Authorized Representative Acknowledgement of Permit Receipt
''"I certify that I am the o%sncr or authori cd agent((Miler's authorisation required)representing the ootiner oI'
the prupert} described abuse,
ii0,1/ As the property owner or authorized representative, I have received the above referenced
perntit(s)as requested in the application for service RBPR-I1-2022-42699, 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
p!!of the permit issued, and further understand that all applicable regulatory requirements specified under the
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North Carolina Laws and Rules for Sewage Treatment and Disposal Systems(ISA NCAC 18A.1900),
and/or Well Construction Standards(1 SA 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: 11/17/2022
Owner/Authorized Representative Signature I
Late //'a4,aa-
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (same of person.sending permit)
Signature £ Date/Time 11.2Q1 ._.
Method: Fax Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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