HomeMy WebLinkAboutIMPV-05-2023-195754.TIF may$' • CATAWBA COUNTY
.�. Public Health Department Subdivision
d , �� Environmental Health Division PINS 363905083120
PO Box 389,25 Government Drive,Newton,NC 28658 LO l'+k
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Site Address: 2108 W NC 10 HWY, NEWTON NC 28658
Name on Permit: SAMUEL BRITTAIN
Property Size: Acres 3.99
Directions: Hwy 10,will need to turn right onto Simmons St(this is where driveway is located for the property)
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-02-2023-43482, by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
7- 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 1 SA.1900),
and/or Well Construction Standards(I5A 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: 05/15/2023
Owner/Authorized Representative Signature
a _
/ Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
oli_ilSignature Date/Time 1)/11)3
Method: Fax y 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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ehpcnnit 05/16/2023 08:22