HomeMy WebLinkAboutAUTH-01-2023-187021.TIF r
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=% CATAW HA COUNTY�a Case#
.t.li Public health Department Subdivision STORYBROOK PH 2
4 Environmental Health Division PI\# 369701183662
n� PO Box 389,25 Government Drive,Neuron,NC 28658 I t)1# 10
Site Address: 3485 STORYBROOK LN, SHERRILLS FORD NC 28673
Name on Permit: 'D&E PROPERTIES, LLC
Property Size: Acres 1.41
Directions: Hwy 16 S to Mt Buleah,turn left Little Mt Rd/subdivistion on right 3/4 mile
Owner/Authorized Representative Acknowledgement of Permit Receipt
iC- 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
4(
permit(s)as requested in the application for service RBPR-12-2022-42993, by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/I..-mail (Return receipt required)
Vii,--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: 01/04/2023 i� / c _`
Owner/Authorized Representative Signature 4 „'
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Date I` f__:.. � ��� =------
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Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/Time )/W/)3
Method: Fax ,/ Email LJS Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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