HomeMy WebLinkAboutEXSY-01-2023-187013.TIF a
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5y 11 tr Public Health Department Subdivision
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ai Gnvironmental Health Divrsu'n PIN# 361802659418
;�� Pt)Box 389,25(iovernmcnt Drive.Newon_NC 28658 Lauri PT 3
Site Address: 3636 ROCKY FORD RD, NEWTON NC 28658
Name on Permit: 'MAYKIA XIONG
Property Size: Acres 4.58
Directions: NC10 Left onto Startown Rd, Right onto Rocky Ford Rd, Turn Right, Property on Left
Owner/Authorized Representative Acknowledgement of Permit Receipt
„Y I certify that I am the owner or authorized agent(owner's authorization required) representing the owner of
the property described above.
J�. rimK As the property owner or authorized representative, I have received the above referenced
ff permit(s)as requested in the application for service ROPR-12-2022-42937,by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
J.
Electronic Image Transmittal/E-mail (Return receipt required)
Y?t. C 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 (I 5A 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 %veil permitted.
Permit Issue Date:01/04/2023
\--tkOwner/Authorized Representative Signature
Date 1 I II 013
Documentation of Permits)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name'a/'person sending permit)
DieSignature Date rime i 11 73
Method: Fax i Email _ (IS Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
We wantt tto hear from yo&Please ttake a few momentts tto complette our custtomer service survey att
httpliwww.surveymorikey.com/s/EHCusttomerService
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