HomeMy WebLinkAboutEXSY-05-2023-195606.TIF ,
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Environmental HealthD;vis,on PIN)) 367804523325
PO Box 389,25 Government Drive.Newton,NC 28658 1.0 t IiXSY•QS-2t123-19$GOb
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Site Address: 4553 NOBLE DR,CATAWBA NC 28609
Name on Permit: GOODSON'S RENTAL, LLC
Property Size: Acres 0.56
Directions: Little Mtn RD.Right Beverly Hills Dr,Left Noble Dr its on the Right
Owner/Authorized Representative Acknowledgement of Permit Receipt
XXG_I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
7 6, As the property owner or authorized representative, l have received the above referenced
permit(s)as requested in the application for service RBPR-02-2023-43550,by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
✓ Electronic Image Transmittal/E-mail (Return receipt required)
11_ As the property owner or authorized representative I have reviewed and understand the specific conditions
it.
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:05/12/2023
Owner/Authorized Representative Signature I� . L� __ _____
Date 6/)-/'-i
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by _ (name u/'person sending permit)
Signature_ _______ Date/"Dime
E.
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Method: Fax I Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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