HomeMy WebLinkAboutAUTH-01-2023-187130.TIF .C� q, cA'(AwBACODUNlY ,
"lilt - Public IIcalth Dcpurunenl Sulxlivision
Envimnmenlsl Itrdlh(livisiun I'tW/ 265703212948
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� PU Roy 3R'),25 Gurennncnt Drive,Newton.NC 28658 LUTN 1
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Site Address: 4009 NC 18 HWY,VALE NC 28168
Name on Permit: 'SW ASSOCIATES,INC
Property Size: Acres 100.02
Directions: Take Hwy10 W(appox 18 miles),right onto Willis Rd,left onto NC 18 Hwy, right onto gravel drive,property is
on the right,will have SWA signs
Owner/Authorized Representative Acknowledgement of Permit Receipt
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-10-2022-42435,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
_J Electronic Image Transmittal/E-mail (Return receipt required)
.i,
-___ As the properly owner or authorized representative I have reviewed anti 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(1SA 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 sup y well permitted.
Permit Issue Date:01/05/2023
Owner/Authorized Representative Signatur€ / -�- �
1 tom,. . -- ..__._
Date _.__�J 42,M
Documentation of Permit(s)'Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (note cycparson sending permit)
Signature.._ °I.
Date/'Time I)O1)3
Method: Fax _ Cmnil US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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