HomeMy WebLinkAboutWELL-07-2023-200854.TIF ,1 4f. ' e CAIAWBA COUNTY
r�, Public Health Department Subdivision
tj,. i Environmental Health Division PINil 366704648018
Ikkr /0OP PO Box 389,25 Government Drive,Newton,NC 28658 LOT#
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Stte Address: 3705 BUFFALO SHOALS RD, MAIDEN NC 28650
Name on Permit: JEFFERY CORNETTE
Property Size: Acres 1.09
Directions: NC 16, Right on Buffalo Shoals Rd, Property on Right
Owner/Authorized Representative Acknowledgement of Permit Receipt
I certify that] 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
((bt• .
NNpermit(s)as requested in the application for service RBPR-04-2023-44023, by the following method(s):
Received in Person I
Facsimile Transmittal (Return form with signature required)
4 Electronic Image Transmittal/E-mail (Return receipt required)
• `/YAs the property owner or authorized representative I have reviewed and understand the specific conditions
it
/of e 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.
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07/25/2023
Representative Signature
Date 1/r d--0D\:3
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name o/'person sending permit)
Signature L�Date/Time ii )3
Method: Fax N 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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