HomeMy WebLinkAboutAUTH-02-2023-189193.TIF 4.,
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• -- Public I lealth Department Subdivision S C HOLLAR ESTATE
fi Environmental Health Division PINK 375501158413
\,1. PO Box 389,25 Government Drive.Newton,NC 28658 LOP: PT 9C&9D
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Site Address: 8099 RIVER BEND RD, CLAREMONT NC 28610
Name on Permit: FORE COMPANY LLC
Property Size: Acres 0.53
Directions: NC 16, right onto River Bend Rd, property on the right
Owner/Authorized Representative Acknowledgement of Permit Receipt
KG I certify that I am the owner or authorized agent(owner's authorization required)representing the owner or
the property described above.
XKG As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service EIIPR-01-2023-43153,by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
I Electronic Image Transmittal/E-mail (Return receipt required)
1. KGAs 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:02/15/2023
Owner/Authorized Representative Signature Kite-- CritZ
`� Date 02/28/2023
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by __._,_._.,...,.-.. (name o/person sending pennil)
Signature - _____ E
qf Date.'Time 4)ist)
Method: Fax J Email US Mail Other
Owner's request to send by the abu\e indicated method of transmittal in lieu of signature Ip
We wantt tto hear from youPlease ttake a few momentts tto complette our custtomer service survey att
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