HomeMy WebLinkAboutIMPV-07-2023-200335.TIF dotloop signature verification:
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CATANBA COUNTY ave IMPV-07-2023-200335
fiPublic health Department Subdivision
Environmental health Division I'INtr 364809157116
PO Box 18'),25 tiovenuncnt Drive.Newton.NC 2&5K i i)1'N 1
Site Address: 2763 S US 321 HWY, NEWTON NC 28658
Name on Permit: TOMMY MCCORKLE
Property Size: Acres.522
Directions: S US 321 Hwy on right past Prison Camp Rd
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Owner/Authorized Representative Acknowledgement of Permit Receipt
Of
2. •v . certify that I am the owner or authorized agent(owner's authorization required)representing the owner al'
atloop verified
the property described above.
s the property owner or authorized representative, I have received the above referenced
per Th(s)as requested in the application for service EHPR-05-2023-44378, by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
T
J Electronic Image Transmittal/ E-mail (Return receipt required)
s the property owner or authorized representative I have reviewed and understand the specific conditions
rJ� oFThe permit issued, and further understand that all applicable regulatory requirements specified under the
North Carolina Laws and Rules for Sewage Treatment and Disposal Systems (I 5A NCAC I8A.1900),
and/or Well Construction Standards(15A NCAC 2C .0100), shall apply to the issuance of this permit and
the construction or the wastewater system and/or water supply well permitted,
Permit Issue Date: 07/17/2023
/t' 1 ///r GG do,loo verified
v 07/27123 2:33 PM FDT
Owner/Authorized Representative Signature__ uxa.,+,zP.oFDs.zo,c
- Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name o/person sending permit)
Signature_ Date/Time f i ,7)'3
Method: Fax `/ Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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