HomeMy WebLinkAboutEXSY-08-2023-201747.TIF t�►t�`y., CATAWBA COUNTY 2p1747
+l t 11111 Public Health Department Case EXSY 08'2023
II Environmental Health Division Subdivision
1)� PO Box 389,25 Government Drive,Newton, PINN 365717011725
NC 28658
Sits Address: LOTH
4110 HE PROPST RD, MAIDEN NC 28650
NaR1e on Permit: JOSE HERNANDEZ
Properly Size: Acres 1.21
Directions:
321 S Bus left onto Island Ford Rd,then immediately turn right onto E Maiden Rd onto Withers Rd, left onto
HE Propst Rd,turn right
Owner/Authorized Representative Acknowledgement of Permit Receipt
X /I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
S2S/j As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service RBPR-06-2023-44710,by the following method(s):
Received in Person
_ Facsimile Transmittal (Return form with signature required)
-L Electronic Image Transmittal/E-mail (Return receipt required)
-rZSlf 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 re
gulatory egulatory 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
Owner/Authorized Representative Signature _rif��� � �,r
Date 9 I i ' ,�
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature �_ Date/Time_ ti 13)
Method: Fax j Email _US Mail
Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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