HomeMy WebLinkAboutIMPV-07-2023-200146.TIF rtib.INCATAWBA COUNTY Case# IMPV-07-2023-200146
Public Health Department Subdivision
• is Environmental Health Division PIN# 266802750121
.....)
PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 1
Site Address: 6283 OLD SHELBY RD,VALE NC 28168
Name on Permit: CHARLES LUTZ
Property Size: Acres 4.294
Directions: Hwy 10 west to Rhoney Rd,at the end of Rhoney turn left onto Old Sheby Rd,go about 3/4 miles and
property on the right
Owner/Authorized Representative Acknowledgement of Permit Receipt
X' 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-06-2023-44518, by the following method(s):
Received in Person
_ Facsimile Transmittal (Return form with signature required)
1 Electronic Image Transmittal/E-mail (Return receipt required)
f' 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 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: 07/14/2023
Owner/Authorized Representative Signature
`✓- Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature t� Date/Time ' ii/J3
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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2fehpennit 07!17 2023 14;I R