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Site Address: 5459 BUCKS GARAGE RD,MAIDEN NC 28650
hams on Permit: JERRY FORBES
Property Size: Acres 1 43
Directions: 16S/left onto old 165,right Bucks Garage Rd/lot on left
Owner/Authorized Representative Acknowledgement of Permit Receipt
XJAI certify that 1 am the owner or authorized agent lowner's authorisation required)representing the owner of
the property described ahtn e.
c i As the property owner or authorized representative. I have received the above referenced
permit(s)as requested in the application for service RBPR-05-2023-44458.by the following methocl(s):
Received in Person
Facsimile Transmittal(Return form v.ith signature required)
.1 Electronic Image Transmittal/E-mail (Return receipt required)
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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: 2(: .0100), shall apply to the issuance of this permit and
the construction of the wastewater system andior water supply well permitted.
Permit Issue Date: 0703.2023
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Owner/Authorized Representative Signature C ,.,--.� fr/c."
~�' Date ..7. ;7.t a 1
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name(o/person serrtlrn,s;permit)
Signature (4 Date/Time '"] J�
a�
Method: Fax I Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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EXISTING SEPTIC SYSTEM INSPECTION
NOT FOR LOAN APPROVAL
Case Number:RBPR-05-2023-44458 _ _ ® Reconnection to Existing System
Property Owner/Applicant:JERRY FORBES ❑ Mobile Home Park Reconnection
Site Address: 5459 BUCKS GARAGE RD,MAIDEN NC 28650 ❑ Applicant Request
Type of Facility: ❑ House ® Mobile Home Number of Bedrooms 3
❑ Business
❑Other
Proposed Addition/Accessory Structure:
®Approved ❑ Not Approved Reason
0 Approval Not Required/System Location Only
Evidence of System Malfunction ❑ YES ® NO System "type/Description GRAVEL TRENCHES
Noncompliance Items and Notes
• Maintain 5 feet min. from any part of septic system with additions.
• No guarantee to the longevity of the existing system.
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7/13/2023
Authorized State Agent \ Date
catawbaeountgrx3,e.gov
Environmental Health
Cotnwbo County Government Center
25 Government Drive I PO Box 389 I Newton NC 28658 182.8.465.8270
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Catawba County Environmental Health
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Parcel: 368601476220, 5459 BUCKS GARAGE l it =60ft
RD MAIDEN, 28650
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Copyright 2023 Catawba County NC
07/13/2023