HomeMy WebLinkAboutAUTH-08-2023-202288.TIF �`v t7- 4 Subdrvlsion
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Public Health Department
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nmenlal Neahh IAv)sion
�� W.. !"Box 389.25 Gmemment Drn c,NC%Strni,NC 28658
Site Addreaa:
8255 W NC 10 HWY•VALE NC 28168
Name on Permit: S
Pr UTPHIN&KANUPP BUILDERS
OP Ir Y size: Acres 1.22
Directions:
'_ NC 10,property on left
Owner/Authorized Representative Acknowletigentcnt of Permit Receipt
xr "1 certify that I am the owner or authorized agent(owner's authorization required)n preventing the owner of
R
the Property described above.
x _b‘As the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service RBPR-07-2023-44953.by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
7 Electronic 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:08/09/2023 )f-
7Owner/Authorid Representativc Signature
-Date 0 p J te) -_--
_.......
r Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature _ _._______._
Date/Time iI l g?3
Method: EatI 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 yotPlease ttake a few momentts tta complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerServlce
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08,09i2021 14 2ti