HomeMy WebLinkAboutWELL-05-2023-195889.TIF 1 ('ACANIIAt 111'NI1'
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Public Ilcalth ikparlment `•ido.ti.,iNn CRESCENT LAND AND TIMBI
.� at tssuonmeutallhalthUnison' trytis 460715641984
,`` PUitwWYt.:SCiu rr vrtncteDsne-Newton,Nl' ;WA I Ma 163
Site Address: 3848 SWANSON RD,SlIERRILLS FORD NC 28673
Wait*on Permit: TRACI DELLINGER
Property Su.: Acres 0 65
Directions: NC 16,felt onto Balls Creek Rd,right onto W Bandys Cross Rd, led onto Buffalo Shoals Rd,then immediately
bear right onto E Bandys Crossroad.right onto Sherrills Ford Rd.righgt Beatty Rd.fen Reid Circle.right
Swanson Rd.property on the left
Iminisiginwiminiminimmilmimigimi(hvncriAuthorized Kepresentalive Acknowledgement of Permit Receipt
0
caul.; that I am the owner in authorized agent pr++rkr's ruihirrilawus required)representing the canner ill11
the property described ahtw e.
i. As the property owner or authorized representative,I have received the above referenced
pet-mitts)as requested in the application for service EIIPR-03.202343707,by the following method(s1:
Received in Person
_ Facsimile Transmittal(Return form with signature required)
I Electronic Image Transmittal/E-mail (Return receipt required)
`( As the property owner or authorized representative I have reviewed and understand the specific conditions
f 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 I8A.1900),
aadfur Well Construction Standards(ISA NCAC 2C.01001, shall apply to the issuance of this permit and
the construction of the wastewater system and'or water supply well permitted.
Permit Issue Date:05r172023 //
Ovsner'Au orila Representative Signature C 2 f / 1 cfr
Date l y � _
Documentation of Permits)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (nwne of permit 3endin}'permit)
(4-
Signature_ E Date l imc G'het/33
Method: _Fos J Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
We wantt no hear from yoaPlease stake a few momenns tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EliCusttomerService
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