HomeMy WebLinkAboutIMPV-01-2023-188159.TIF h r
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`'t ilri'w CATAWBA COUNTY
��r-;; Public Health Department Subdivision JOHN F LUTZ PROP UNRECC
ql`,; it Environmental Health Division PINtt 365701283706
',\4 PO Box 389,25 Government Drive.Newton,NC 28658 LOU
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Site Address: 3412 BRIARWOOD DR, MAIDEN NC 28650
Name on Permit ITANDEWI AGUILAR
Property Size: Acres 0.72
Directions: 321 left onto Prison Camp Rd,right on Jack Whitener Rd,right on St.James Ch Rd, left on Campbell Rd,left
on Providence Mill Rd, right on Ashwood St,right on Brianwood Dr, propety on the left
1
Owner/Authorized Representative Acknowledgement of Permit Receipt
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
rmit(s)as requested in the application for service Rl3PR-111-2022-42789,by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
X..X
s the property owner or authorized representative I have reviewed and understand the specific conditions
o he permit issued, and further understand that all applicable regulatory requirements specified under the
North Carolina Laws and Rules for Sewage Treatment and Disposal Systems(I5A NCAC I8A.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:01/26/2023
ItanrIPMil artI filar
Owner>Auth 'zed Repentative Signature�,-„_______.....__.�.. ..._..
-� DatD 2/02/2024
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
,
Permit transmitted by 4 . person
- Date/'Time epj)j)3
Method: Fax J 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 yoa;Please ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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