HomeMy WebLinkAboutIMPV-02-2023-189675.TIF t. _ , CATAWBA COUNTY
ill
ti/` Public Health Department Subdivision
s Environmental Health Division
l"sR PINS 365803414521
'�� . PO Box 389,25 Government Drive,Newton,NC 28658 LOT% 2
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efts Address: 2383 HENDRIX RD,MAIDEN NC 28650
Hams on Permit TRAVIS OSBORNE
Property Size: Acres 42.01
Directions: Right off of Providence Mill Rd onto Hendrix Rd. Use right of way to enter lot.
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.
76 As the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service RBPR-I1-2022-42907,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
v. Electronic Image Transmittal/E-mail (Return receipt required)
it76_ 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:02/20/2023 _
Owner/Authorized Representative Signature
Date Z-e6-Z3
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person se ding relit))
Signature4 Date/Time ) J3
Method: Fax `4 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 yoaPlease Rake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.corn/s/EfitusttomerService
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