HomeMy WebLinkAboutAUTH-06-2023-198539.TIF 4 L Pubic Ilcallh t)rpanmcnt �daJl�...ion
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SIB Address: 4637 BANDYS SPRINGS RD. CATAWBA NC 28609
Name on Permit DALLAS HENNEBORN
Property Size: Acres 1 01
Directions: Left on Government DR.250 ft Right SW Blvd 0 1 mi Left W C ST.2 7 mi continue on NC 16. 2 7 mi Left
Balls Creek, Right Little MT RD• Left Caldwell RD Continue to Bandys Spring RD
Owner/Authorized Representative Acknowledgement of Permit Receipt
X' ertifs that 1 am the ossner or authorised agent((miler's authorisation required)representing the owner of
e property described abuse.
/4- s the property usyncr or authorized representatise. I have received the above referenced
.rtnit(s)as requested in the application for sers ice KBPK-03-2023-43874. by the tiillossing inethod(s):
2
Received in Person
s Facsimile Transmittal (Return form ssith signature required)
Electronic Image Transmittal: E-mail (Return receipt required)
s the property owner or authorized representative I hase 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(I5A NC'AC IRA.191H)),
and/or Well Construction Standards(15A NC'A(' 2(' .0100), shall apply to the issuance of this permit and
the construction of the ssastessater ssstein and"or ssater supply ssell permitted.
Permit Issue Date: 06/21/2023
Owner'Authorized Representative Signature
Date_ 00)3A(Z4
Documentation of l'ermit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by _ (namee r+/p'ro,:.ccvrrlt,g/'ern► l)
Signature tj DJ1C.'Tlllle C\itf913o j -3
Method: Fax Ni Email (IS Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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