HomeMy WebLinkAboutEXSY-09-2023-204097.TIF .�,.� e4jr, CATAWBA COUNTY,
Case l! EXSY-09-2023-204097
iI -'- Gee Public Health Department Subdivision ANNIE TRACE
►,s _.., _ is Environmental Health Division PINK 377108988380
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PO Box 389,25 Government Drive,Newton,NC 28658 LOIN 32
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Site Address: 2576 1ST AVE NW, CATAWBA NC 28609
Hanes on Permit JEROME SMYRE
Property Size: Acres 0.37
Directions: Right SW Blvd, Left W C ST, Left Hwy 10 E,Left 5th ST SW,Left 1stAv NW
Owner/Authorized Representative Acknowledgement of Permit Receipt
KI 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
permits)as requested in the application for service RBPR-06-2023-44740,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
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
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North Carolina Laws and Rules for Sewage Treatment and Disposal Systems(I5A 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:09/06/2023 i
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Owner/Authorized Representative Signature
Date ` 7'- . ` S
Documentation of Permit(s)Transmittal
(permit transmitted byelectronic or other means)
Permit transmitted b (name of person sen rnglpermit)
Signature Date/Time `/TJ �!�_
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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ehpermu 09/07/2023 11:23