HomeMy WebLinkAboutEXSY-04-2023-194295.TIF i.
41g: • CATAW'BA CO1.1NTY Case# EXSY-04-2023-194295
ti , , Public Health Department Subdivision
d Environmental Health Division PIN# 266802581024
PO Box 389,25 Government Drive,Newton,NC 28658 i.o r# TR 2
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Site Address: 8747 JACOB FORK RIVER RD,VALE NC 28168
Name on Permit: *DONALD WYATT
Property Size: Acres 30.92
Directions: Hwy NC 10 Right onto Providence Church RD, Left Old Shelby Rd, Right Jacob Fork RD property on left
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 property described above.
,(....,-At he property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service RBPR-04-2023-44076,by the following method(s):
Received in Person
_ Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
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s 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: 04/25/2023 /
Owner/Authorized Representative Signatur -s
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'� d J Date ?��
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/Time
Method: Fax 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 04/26/2023 05:52