HomeMy WebLinkAboutEXSY-01-2023-187571.TIF a+'t fir. CATAWBACOU'NT% Cana EXSY-01-2023-187571
.y/ Pub c Health Department Suthdr.I%Ion CRESCENT LAND AND TIMBI
•.\ �le Environmental Health Division PINK 462802570825
;ss,,,,101PPo Box 389.25 Govcrnmcnt I)n c..Newton.NC 2fM5t LOIN 298ADJ
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Site Address; 2541 CROSSGATE TR, SHERRILLS FORD NC 28673
Name on Permit: SANDRA AND FRANK HARLOW
Property Size: Acres 0.71
Directions: Sherrilts Ford Rd,right Island Point Rd.left Bayleaf Ln,Crossgate Tr,on left
Owner/Authorized Representative Acknowledgement of Permit Receipt
l(certity that I am the owner or authorized agent(owner's authorization required)representing the owner of
thc pr pert) described atwve.
N /
�r✓f/As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service RBPR-I2-2022-42927, by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
IElectronic Image Transmittal/E-mail (Return receipt required)
r:_✓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(l5A NCAC 18A.I91)0),
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:01/13/2023
.1-
Owner/Authorized Representative Signature Lam"2.C�✓f/'.:4-v�--
Date t (.7 ( 1 2 3 `
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sendrng pernr(1)
Signature9 )late/Time �1 )3
Method: Fax J Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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