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Site Address: 2674 SARDIS CHURCH RD.HICKORY NC 28602
Name on Permit: LANE FULBRIGHT
Property Size: Acres 4 28
Directions: Left off of W NC 10 Hwy onto Sardis Church Rd.3rd lot on left.
Owner/Authorized Representative Acknowledgement of Permit Receipt
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�` I certil} that I ant the oft n s cr or authorized agent tots authorization required)rcprescn(ing the rtcncr Of
{{ the property demerill d abate.
L1 As the property owner or authorized representative.I have received the above referenced
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permit(s)as requested in the application 'Or service RBI'K-IO-2022-42500.by the following method(s):
Received in Person
1 Facsimile Transmittal(Return firm with signature required)
Electronic Image Transmittal- E-mail (Return receipt required)
14.
(..—k"+1s the property owner or authorized representative I have ref iewed 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 oI'this permit and
the construction ol'the wastewater system and/or water supply well permitted.
Permit Issue Date: 11/22)2022
Owner'Authnrized Representative Signature
Date 1W
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by . . /tutu'ol.person seralipt,l;permit)
CifSignature I)alc''titne iu 5i`1
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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