HomeMy WebLinkAboutAUTH-02-2023-189944.TIF (:ATAwBACOUNTY Case A 7•II-02-2023-189944
Public Health Department Subdivision HOMESTEAD PARK
4`� Environmental Health Division PIN# 374409253400
pt 1v . PO Box 389,25 Government Drive.Newton.NC 28658 1.OTH PT4
She Address: 1221 STEPHENS ST, CONOVER NC 28613
Name on Permit: YANG THAO
Property Size: Acres 0 4
Directions: NC 16, left onto C and B Farm Rd,right onto Lee Cline Rd, left onto Houston Mill Rd, right onto Houston Dr•
left onto Pecan St,nghto onto Stephens St, property on the nght
Owner/Authorized Representative Acknowledgement of Permit Receipt
. "(ItI certify.that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
i (V. As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service EHPR-01-2023-43291, by the following method(s):
Received in Person
_ Facsimile Transmittal(Return form with signature required)
./ Electronic Image Transmittal/E-mail (Return receipt required)
1.1• 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.
1
1 Permit Issue Date:02/24/2023
Owner/Authorized Representative Signature -.1
Date 3 12-025 —
Documentation of Permits)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending;permit)
Signature ....-.--47. Date/Time :�
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 compiette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomer5ervice
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