HomeMy WebLinkAboutEXSY-04-2023-193758.TIF CATAt1BACoUcTl'• fli p r C'a;ca I:XSY-Oa•2023-193758
Public Health Depanmem Subdivision
Environmental Health Division PINS
Lr 269701299709
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PO Box 389,25 Government Drive,Newton NC 28658
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Site Address: 3219 LEDFORD RD,VALE NC 28168
Name on Permit: TYLER REINHARDT
Property Size: Acres 1.47
Directions: Hwy 10 W, Left on Heavner Rd, at end of Heavner• Right on Ledford, Property on Right
Owner/Authorized Representative Acknowledgement of Permit Receipt
!` � certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the.�Q roperty 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-03-2023-43818, by the tollowing method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
T Electronic Image"Transmittal/E-mail (Return receipt required)
y,‘-'4Z-9---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: 04/17/2023
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Owner/Authorized Representative Signature _
_ r Date \/%*‘\1.,Q)?A--
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name o/person sending permit)
Signature '
Date/'Time 13/23
Method: Fax 4 Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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