HomeMy WebLinkAboutIMPV-03-2023-190660.TIF �� CATAWBA COUNTY ..,.... __ ____
t. ,, Public Health Department Subdivision GUY E HOLLAR
d .� Environmental Health Division PIN# 375209074492
PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 11
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Site Address: 3445 ALFALFA ST NE, CONOVER NC 28613
Name on Permit: DORU BERBEC
Property Size: Acres 0.73
Directions: from Hwy 16 Conover, right St Johns Chuch Rd/Right Alfalfa St/lot is on right
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-02-2023-43314, by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
7. Electronic 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: 03/07/2023
a Owner/Authorized Representative Signature
/ Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name or person sending permit)
Signature Date/Time - )) i/ ,3
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 ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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ehpennit 03/08/2023 06:43