HomeMy WebLinkAboutAUTH-03-2023-192168.TIF + (',1T.111'It.1('Ol'\'I'1 Case•
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Site Address: 6475 GRACIE LN.VALE NC 28168
Name on Permit: KELLY 8 AUDRA LEONHAROT
Property Size: Acres 2.19
Directions: Head Won Hwy 10 to approx 12 miles property is on the corner of Hwy 10 and Gracie LN
Owner/Authorized Representative Acknowledgement of Permit Receipt
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a, I certit\ that I :tin the owner or authorized agent(owner's;wlhuri/atiun required representing the t'c ncr of
the propene described abo‘c.
r�yt( As the property owner or authorized representative. I have received the above referenced
permit(s)as requested in the application for service RI3l'R-01-2023-43219,by the following method(s):
Received in Person
Facsimile Transmittal (Return lien) with signature required)
+ Electronic Image Transmittal/ li-mail (Return receipt required)
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)((1_.)t 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 Dale: 03/24/2023 *//Owner/Authorized Representative Signature ���.i�( }�7--
=1 Date ELLI _ tc2 3 .. _
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name n/person son sending permit)
Signature _ Date!Time /f�01��
Method: Fax Entail US Mail Other
Owner's request to send by the above indicated method o1'transmittal in lieu of'signature
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