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CATAWBA COUNTY Case itIMPV-01-2023-187426
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• �. Public health Department Subdivision KNOLLS POINT
2,R la.,' Environmental health Division PIN# 374501055797
PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 4 &5
Site Address: 6270 RUFFIN LN,CONOVER NC 28613
Name on Permit RYAN TOMBLIN
Property Size: Acres 1.74
Directions: Springs Rd to St. Peters Ch Rd, St. Peters Ch Rd, turn onto Monford Dr,follow Monford Dr until you see
Ruffin Ln on the right. If you get to the Campground you have gone too far.
Owner/Authorized Representative Acknowledgement of Permit Receipt
,e%i certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
Y ,4%As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service EHPR-11-2022-42717,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
7 Electronic Image Transmittal/E-mail (Return receipt required)
,Q%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:01/11/2023
Owner/Authorized Representative Signature
Date 01/19/2023
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature 0,,E Date/Time Iiied)3
it
Method: Fax V 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 youPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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