HomeMy WebLinkAboutAUTH-03-2023-190501.TIF e�y, CATA1*w'BACOLNT1' C,scH AUf}I-03 2023-140501
�r - Public Health Department Subdivision C BALLARD AND M SHERRIL j
i , s Environmental Health Division
S '^(: PINb 461704722778
�:ilt PO Box 389,25 Government Deive,Newton,NC 28658 1.00 3 8 PT 2
Site Address: 8748 PENINSULA DR,TERRELL NC 28682
Name on Permit: CHRIS MITLITSKY
Property Size: Acres 0.71
Directions: Hwy 150 E,right Kiser Island Rd,left Peninsula Dr on nght
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.
X`nAs the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service EHPR-08-2022-41958,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
7 Electronic Image Transmittal/E-mail (Return receipt required)
i/�C. As the property owner or authorized representative I have reviewed and understand the specific conditions
1 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.
::;:
03/02/2023
Representative Signatur
Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by __ (name of person sending permit)
if)
Signature Date/Time 31,&) 3
Method: Fax I Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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