HomeMy WebLinkAboutIMPV-01-2023-187074.TIF �jt►7ra CATAWBA COUNTY Cases
r�7 't' Public Health Department Subdivision
it: Environmental Health Division
� PtNa 361601089405
•i. PO Box 389,25 Government Drive.Newton,NC 28658 l o r t Z
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Ski Address: 4485 PAINT SHOP RD, LINCOLNTON NC 28092
Name on Permit: KIMBER COLEMAN
Property Size: Acres 1.78
Directions: Left off of Reepsville Rd onto Paint Shop Rd. Lot on left,across rd from 4486 Paint Shop Rd
Owner/Authorized Representative Acknowledgement of Permit Receipt
Kti‘\)I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
r'!7 As the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service RBPR-10-2022-42506,by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
1 Electronic Image Transmittal/E-mail (Return receipt required)
t. W 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 I8A.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.
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Representative Signature ,
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Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name ojperson sending permit)
Signaturelc - l)ate/'l'irnej 7 D1 7 3
Method: Fax 'I 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 yoiPlease ttake a few momentts tto complette our custtomer service survey aft
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