HomeMy WebLinkAboutAUTH-08-2023-202195.TIF emcee Alm I-08-2023-202195 1
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.��r Public Health Department P'i 1P 371212961122
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PO Dos 309.25 Government(hive.Newton.NC 286511
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Site Address: 623 21ST ST SE.HICKORY NC 28602
Name on Permit: ELIJAH LONDON
Property Size: Acres 0.82
US 321,left onto 2nd Ave NW,right onto 23rd St NW,right onto 6th Ave NW,left onto 21st St NW
Directions:
Owner/Authorized Representative Acknowledgement of Permit Receipt
x&U certify that I um the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
xa As the property owner or authorized representative.I have received the above referenced
permit(s)as requested in the application for service EHPR-08-2023-45150,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
7 Electronic Image'I'ransmittal/E-mail (Return receipt required)
El—As the properly 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:08/09/2023
Owner/Authorized Representative Signature____ ___......../
Date . /. __
Documentation of Permits)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by_ (name of person sending permit)
Signature____,-_ rr Date/Time�1)'17J
C
Method: _Fax ' 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 comptette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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