HomeMy WebLinkAboutEXSY-02-2023-189215.TIF CATAWBA COUNTY Case# EXSY-02-2023-189215
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�-It Public Health Department ;3 , Subdivision
Environmental Health Division PIN# 363611764749
PO Box 389,25 Government Drive,Newton,NC 28658 LOT#
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Site Address: 134 GIBBS CIR, MAIDEN NC 28650
Name on Permit: DEVARTA MONROE
Property Size: Acres 1.76
Directions: From salem church rd you would need to make turn on Gibbs circle and drive to the home at the end on the
left
Owner/Authorized Representative Acknowledgement of Permit Receipt
I 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
permit(s)as requested in the application for service RBPR-1 0-202 1-391 40,by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
iElectronic Image Transmittal/E-mail (Return receipt required)
)( 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: 02/15/2023
Owner/Authorized Representative Signature
Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by_ (name ofperson sending_ permit)
SignatureqE i Date/Time1�c /)3
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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 yoiPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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clipennit 02/15/2023 14:34