HomeMy WebLinkAboutWELL-03-2023-192031.TIF r
dyea CATAWBA COUNTY ... _ _.
.t. ,. Public Health Department cz
Subdivision LUTHER COWANS SHERRILI
"'j Environmental Health Division PIN#"r!! 46280265053076
PO Box 389,25 Government Drive,Newton,NC 28658 I.0
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Site Address: 9481 RIVIERA DR, SHERRILLS FORD NC 28673
Name on Permit: ELMIRA HOUSTON WHITE
Property Size: Acres 0.51
Directions: Take Island Pointe Rd to Riviera Dr and make a left.The lot is 200ft on right.
Owner/Authorized Representative Acknowledgement of Permit Receipt
X _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-02-2023-43347,by the following tnethod(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: 03/23/2023
Owner/Authorized Representative Signature
Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name ofperson sending permit)
Signature f- Date/Time It/
Method: Fax J Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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ehpennit 03/24/2023 06:52