HomeMy WebLinkAboutIMPV-03-2023-191466.TIF 4 !
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Public Health Department Sutxtnism W ism PH 2
er Environmental Health Division I'lNf1 367804622244
PO lion 389.25 Government Drive.Newton,NC' 28658 LCYfir 40
Site Addr ss: 4525 NORTH WYNSWEPT OR, MAIDEN NC 28650
Name on Permit: MODLIN CONSTRUCTION INC
Property Size: Acres 0.71
Directions: Hwy 16 S Towards Denver,once pass Buffalo Shoals intersection,Wynswept on left
Owner/Authorized Representative Acknowledgement of Permit Receipt
X __ I certify that I am the owner or authorized agent;owner's authnriiation required)representing the owner of
the property described above.
XAs the property owner or authorized representative, I have received the above referenced
fi as requested in the application for service RBPR-12-2022-43086, by the following method(s):
ceivcd in Person
Facsimile Transmittal (Return form with signature required)
1 Electronic Image Transmittal!E-mail (Return receipt required)
iAs 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(I SA NCAC 18A.1900),
and/or Well Construction Standards(ISA 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:03/16/2023
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Owner/Authorized Representative Signature
.'1 Date 3/Z ..ZP ...
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name n/'person sending hermit)
Signature _ .2 Date/Time )3 f)3
Method: Fax Y 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 mornentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/DiCusttomerService
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