HomeMy WebLinkAboutIMPV-05-2023-195156.TIF .21 CAPAWBA COUNTY
Public Health Department Subdivision
Environmental Health Division PIN# 373306298743
PO Box 389,25 Government Drive,Newton,NC 28658 LOT#
IH42
Site Address: 4846 COUNTY HOME RD. CONOVER NC 28613
Name on Permit: KRISTI TUCKER
Property Size: Acres 0.9
Directions: 321 N Bus, right onto W 20th St, left onto NC 16 Bus, left onto County Home Rd, at the roundabout take the 2
nd exit, property on the right
Owner/Authorized Representative Acknowledgement of Permit Receipt
__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 EHPR-01-2023-43261, by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
TElectronic 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: 05/08/2023
Owner/Authorized Representative Signature
( Date
fi/1/c M
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/Time 51 10J)3
Method: Fax s Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
We wantt tto hear from yoiPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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ehpennil 05/10/2023 05:27