HomeMy WebLinkAboutWELL-06-2023-197400.TIF 41= . CATAWBA COUNTY Case WELL-06-2023-197400
.� illi 2 Public Health Department Subdivision
Environmental Health Division JINN 361801087291
PO Box 389,25 Government Drive,Newton,NC 28658 LOT#
R.
Site Address: 3820 HICKORY LINCOLNTON HWY, HICKORY NC 28658
Name on Permit: WK DICKSON
Property Size: Acres 5.95
Directions: W NC 10 Hwy left Hickory Lincolnton Hwy, on left before Old State Rd
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.
XAs the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service EHPR-04-2023-44063, by the following method(s):
Received in Person
_ Facsimile Transmittal(Return form with signature required)
V 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 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: 06/06/2023
Owner/Authorized Representative Signature
'.'ir Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
�rfSignatureqv/C., Date/Time 6 l 11�3
Method: Fax ` 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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ehpennit 06/07/2023 06.55