HomeMy WebLinkAboutIMPV-01-2023-187059.TIF Av7Nrif. CATAWBA COCNTV Case
li.�,..t a, Public Health Department Suhdiviuon PINE BURR
l ['Jt Environmental Health Division PIN,/ 368703416458
1�\�� PO Box 1119,25 Government Dnve,Newton,NC 2s65t LOTt 1 &5
stt.Address: 4172 WNONA DR.MAIDEN NC 28850
Nan on Permit 'RICHARD(LOGAN)RIDDLE
Property Stza: Acres 1.03
Directions: S Hwy 16,Left on Mt Beulah Right on Winona Lot of left
n1 Owner/Authorized Representative Acknowledgement of Permit Receipt
certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
f the property described above.
(1/41` 'As the property owner or authorized representative,I have received the above referenced
perrnit(s)as requested in the application for service RBPR-04-2022-40586,by the following method(s): -
_ Received in Person
Facsimile Transmittal(Return form with signature required)
/Electronic Image Transmittal/E-mail (Return receipt required)
gAs the property owner or authorized representative 1 have reviewed and understand the specific conditions
?6-2.
of the permit issued, and further understand that all applicable regulatory requirements specified under;he
Nor-lb Carolina Laws and Rules for Sewage Treatment and Disposal Systems(l5A NCAC 18A.1900).
sad/or Well Construction Standards(1SA 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:08/10/2022
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Owner/Authorized Representative Signature
Date 1-11—.)-va3
Documentation of Permit(s)'Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signaturecie 1
Date/Time )l i )
Method: ___Fax Email lJS Mail _ Other
Owner's request to send by the above Indicated method of transmittal in lieu of signature
We wantt tto hear from yoxPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveyymonhey.corn/s/EHCusttomerServlce
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