HomeMy WebLinkAboutAUTH-09-2023-204401.tif e ^v.10+Y, CATA'WBACOUNTY Case N AUTII-09-2023-204401
Public Health Department Subdivision Tranquil Village
��. )s Environmental Health Division PIN# 373411659102
/0 PO Box 389,25 Government Drive.Newton.NC 28658 i nt 6
/IVSite Address: 5213 HALL ST,CONOVER NC 28613
Name on Permit: SHUA CHA
Property Size: Acres.42
Directions: springs rd, right on hall st,property on right
Owner/Authorized Representative Acknowledgement of Permit Receipt
5A1 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 EHPR-05-2023-44324, by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
yt/Electronic Image Transmittal/E-mail (Return receipt required)
CPAs the property owner or authorized representative 1 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(I5A 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:09/11/2023
Owner/Authorized Representative Signature
Date Au a 3
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name ofperson sending permit)
12.
Signature Date/Time ,9 "fW
Method: Fax `r 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 complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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Catawba County Environmental Health
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09108P2023
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