HomeMy WebLinkAboutIMPV-12-2022-186464.TIF C��e CATAWBACOLINTY
CaseH IMPV-12.2022-186464
Public Health Department Subdivision
a Environmental Health Division PINt 460701095413
3�/10 PO Box 389,25 Government Drive,Newton,NC 28658 LOTH 3
it:ftSite Address: 6853 LOCKE DR,SHERRILLS FORD NC 28673
Name on Permit KEVIN LYNCH
Property Size: Acres 1.127
Directions: NC 10,right onto Murrays Mill Rd,left onto Shemlls Ford Rd,right onto Mount Pleasant Rd.right onto Locke
Dr,propety on the left
Owner/Authorized Representative Acknowledgement of Permit Receipt
It(
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I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
As the proper[}'owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service EHPR-09-2022-42300,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
—"Facsimile
Image Transmittal/E-mail (Return receipt required)
1 l'VAs As the property owner or authorized representative I have reviewed and understand the specific conditions
o�fthe 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
it
(Owner/Authorized Representative Signature
` Date . o//l�/2.3
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by_ (name ofperson se ing permit)
Signature
f g. Date/'Time? ft D3
Method: Fax /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 yosPlease ttake a few momentts tto complette our custtomer service survey art
http://www.surveymonkey.com/s/E1iCusttomerServIce
Kit/W.60h rq set eg ta 6w)
ehparmit 12/212022 10-75
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