HomeMy WebLinkAboutAUTH-05-2023-195233.TIF 6 _ CATAWBA COUNTY _-_
�, Public Health Department Subdivision
Environmental Health Division PIN# 267903037627
PO Box 389,25 Government Drive,Newton,NC 2865R LOT#
/842 sr
Site Address: 4972 OLD SHELBY RD, VALE NC 28168
Name on Permit: MELANIE STUBBS
Property Size: Acres 35.68
Directions: Hwy 10, Turn Right onto Providence Ch Rd to end turn left Old Shelby Rd, Property on corner and left
Owner/Authorized Representative Acknowledgement of Permit Receipt
_1 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 RBPR-04-2023-44024,by the following method(s):
Received in Person
_ Facsimile Transmittal(Return form with signature required)
Electronic 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.
1.
Permit Issue Date:05/09/2023
Owner/Authorized Representative Signature
Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
t
Signature �' Date/Time .51) 53
Method: Fax V Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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http://www.surveymonkey.com/s/EHCusttomerService
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ehpennit 05/10/2023 06:42