HomeMy WebLinkAboutAUTH-02-2023-189205.TIF P1 480701380146
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.'.r -, r FORD NC 28673
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°t:'•mailbox south of Camp Dogwood on Mt Pleasant RD Gate code 2425 Park next to trailer end of path
prapertyon Ie8
Owner/Authorized Representative Acknowledgement of Permit Receipt
X 'certify that I urn the owner or authorized agent(owner's authorization required)representing the owner
'/ t mperty described Elbow.
l' As the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service RItPR-1I-2022-42759,by the following method(s):
•
Received in Person
Facsimile Transmittal(Return form with signature required)
V Electronic Image Transmittal/E-mail (Return receipt required)
slAs the property owner or authorized representative I have reviewed and understand the specific conditions
401
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(I5A 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 Dale:02/15/2023
Owner/Authorized Representative Signature ICLUt1224_ _ —
4-1
Date ti_ig1
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
_ Permit transmitted by. (name of person sending permit) -
Signature _ Date/Time314T)3
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Method: Fax '+ Email US Mall Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
We wantt tto hear from ywPlease stake a few momentts tto complette our custtomer service survey att.
http://www.surveymonkey.com/s/EH CusttomerService
I,07ltui 02ll 112023 1109