HomeMy WebLinkAboutAUTH-05-2023-196957.TIF •
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0 . Public I tcalth Department Subdt.won NORA LYNN ISAAC SIGMON
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..1 tr I•.numnmrnul Health Omicron Plhit 376403117595
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_ . Pll Ito%04 25(1m:emmrnt rkrse.Ncuton is 21M5K tutu 18 8 22
Site Address: 5522 RIVER BEND RD.CLAREMONT NC 28610
Name on Permit- BELYNDA TEAL
Property Size Acres 1.16
Directions Hwy 16 to RiverBend Rd.approximately 34 mikes,property on the right
Owner/Authorized Representative Acknowledgement of Permit Receipt
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I I certily that I am the owner or authorized agent(owner's authorization required)representing the nssner of
the property described above.
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)( __ As the property owner or authorized representative,I have received the above referenced
1 permit(s)as requested in the application fi'r sers ice E".HPR-05-2023-44333,by the following method(s):
............
Received in Person
Facsimile transmittal(Return form with signature required)
f. Electronic Image Transmittal.'E-mail (Return receipt required)
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+ - •__ As the property owner or authorized representative I have reviewed and understand the specific conditions
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of the permit issued, and further understand that all applicable regulatory requirements specified under the
North Carolina laws and Rules for tiers age Treatment and Disposal Systems(15A NCAC 18A.1900),
and/or Well Construction Standards(I SA 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 Datei 05/31r2023 .14 _�
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()utter Authorized Representative Signature r _ .. ____
••1 Date 6/12/23
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of persan sending permit)
Signature CrE Date'Time 1117/13
Method: Fax J Email L:S Mail Other
Owner's request to send by the atone indicated method of transmittal in lieu of signature
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