HomeMy WebLinkAboutAUTH-03-2023-190829.TIF I ,
l • CATAWBA COUNTY
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.1.` Public Health Department Subdivision CHARLES WiLSON AND WILL
• , , i Environmental Health Division I'IN# 4860701365921
PO Box 389,25 Government Drive,Newton,NC 28658 1,0'f# 8
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Site Address: 3602 DOCKSIDE LN, SHERRILLS FORD NC 28673
Name on Permit: LARRY LUPORI
Property Size: Acres 0.76
Directions: Govt Dr to SW BLVD, Hwy 16S to Lil Mt Rd to Dockside
Owner/Authorized Representative Acknowledgement of Permit Receipt
KI 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-01-2023-43161, by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
,/ Electronic Image Transmittal/E-mail (Return receipt required)
•r 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: 03/09/2023
Owner/Authorized Representative Signature
a Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by _ (name ofperson sending permit)
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Signature Date/Time
Method: Fax i 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 yol.Please ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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elipernit 03/10/2023 09:18