HomeMy WebLinkAboutIMPV-12-2022-186421.TIF .1yi�. CPATAWBAl COUNTY
13: .f. , , Public Health Department Subdivision FAIRWAY ACRES
,"L '��, Environmental Health Division PIN 372017021060
PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 5
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Site Address: 2988 QUAIL DR, NEWTON NC 28658
Name on Permit: *J&M PROPERTY INVESTMENT LLC
Property Size: Acres 0.58
Directions: Startown left Sandy Ford, Left Chestnut, Right Rosewood, Left Fairway, Right Quail Dr
Owner/Authorized Representative Acknowledgement of Permit Receipt
pi( I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service RBPR-10-2022-42477,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
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: 12/20/2022
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)
Signature E Date/Time f/j i l
Method: Fax f Email US Mail 1 Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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ehpermit 12/20/2022 15:10 r