HomeMy WebLinkAboutWELL-11-2022-185304.TIF 4.v�Y% ('ATA11
1 t Public II ,i .Is,,,nknl Subdivision 1NYNSWEPT PH 5.2
r r s Envimnnlental I kuhh Division
'i 'ot IINM 367804618180
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Site Address: 4653 CAYTON DR,MAIDEN NC 28650
Name on Permit: 'NEST HOMES LIC
Property Size: Acres 0,76
Directions: Intersection of Buffalo Shoals Rd&NC 16 S; NC 16S to left on Cayton Dr
Owner/Authorized Representative Acknowledgement of Permit Receipt
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1 certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
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the property described above.
As the property owner or authorized representative. I have received the above referenced
pennit(s)as requested in the application for service R13PR-08-2022-41950,by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
_
._J Electronic Image Transmittal/E-mail (Return receipt required)
As the property owner or authorized representative I have reviewed and understand the specific conditions
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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(ISA 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: 11/30/2022
Owner/Authorized Representative Signature p
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Date I d.•tp- 2c22.-2—
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name 0/person sending permit)
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Signature _ t Datc/•Time f? ?Z —
Method: Fax i/ Email US Mail Niher.
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
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