HomeMy WebLinkAboutIMPV-04-2023-194622.TIF nr,SATI•\ (.S1:au 8.1(•Ot'\TY
`r 'j+ .../1 Valle Ileanti Departmentr, I nvrronmental health Ihvrsum \r,h ,,„r,,,:
Prtnox389.25Government!hr,e..No��ton.Nt' 2kR51; I'Ixu 1' 370018320184
site Address: 4900 PITTSTOWN RD• HICKORY NC 28602 I rtr,r
Name on Permit DANIEL 8 RANA BROOKS
Property Size: Acres 24.8
Directions: I-40W to exit 123A. US321S. take 321S to exit#41 River Rd. left on Zion Ch Rd. Right on Ptttstown R
Property on Right d
Owner/Authorized Representative Acknowledgement of Permit Receipt
Ccrrtitj that I am the owner or authorized agent (owner's auth,,rifalin the property described ahoy c, n required I representing the t,vvner orK
. . erenced
,,, , As the property owner or authorized representative. I hate received
permit(s)as requested in the application for service 1tHPR-03-2023-13828`b) the Iiiltlowinsz method(s):
Received in Person
Facsimile"transmittal (Return torn) with signature required)
N/ Electronic Image Transmittal/E-mail (Return receipt required)
, .) CC-i ..-
As the property owner or authorized re s
nd understand the
of the permit issued, and further understand that all applicable requirementsregulatory a s specified sunder the
fic tions
North Carolina Laws and Rules for Sewage Treatment and Disposal Systems (I SA NCAC 18A.1900),
and/or Well Construction Standards (I SA NCAC 2C.11100), shall apply to the issuance of this permit and
the construction of the wastewater system and/or water supply '‘.cII permitted.
Permit Issue Date: 04/28/2023
Owncr'Authorized Representative Signatu -
Date 5 .`.'1—
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by
manor f11 p,,rv(117 sending penult)
qii
Signature
Date. time 6/7/1)
Method: Fax .I_(;mail (!S Mail
Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
We wantt tto hear from yoiPlease stake a few momentts tto comptette our custtomer service survey aft
http://www.surveymonkey.com/s/EHCusttomerService
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Catawba County Environmental Health
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Parcel: 370018320184, 4900 PITTSTOWN RD lin=60ft
HICKORY, 28602
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04/27/2023