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CATAWBA COUNTY Case# IMPV 08-2023-201661
tPublic Health Department Subdivision
. Environmental Health Division PIN# 268703314289
' PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 1
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Site Address: 4194 BANOAK RD, VALE NC 28168
Name on Permit: MATTHEW MARTIN
Property Size: Acres 5
Directions: coming from newton on Hwy 10 Left onto Banoak RD House is 1 mi from school on left
Owner/Authorized Representative Acknowledgement of Permit Receipt
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 RBPR-07-2023-44938,by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
IElectronic Image Transmittal/E-mail (Return receipt required)
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: 08/03/2023
r 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)
SignatureCif Date/Time 4:6f f7/)3
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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http://www.surveymonkey.com/s/EHCusttomerService
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