HomeMy WebLinkAboutWELL-09-2023-205021.TIF Qv;14�a CATAWBA COUNTY
t ;� Public Health Department Subdivision
}R,, •- Environmental Health Division PINK 2t38904538221
PO Box 389,25 Government Drive,Newton,NC 28658 LOTN 2
Site Address: 8414 ORA LN,VALE NC 28168
Name on Permit: CHAD CANIPE
Property Size: Acres 3.37
Directions: Old Shelby Rd to Jacob Fork River RD to Ora Ln
Owner/Authorized Representative Acknowledgement of Permit Receipt
b/I 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 RBPR-06-2023-44707,by the following method(s):
Received in Person
__ Facsimile Transmittal(Return form with signature required)
1Y Electronic Image Transmittal/E-mail (Return receipt required)
_yAs 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: 09/19/2023
Owner/Authorized Representative Signature L%'%�✓t
Date QA/.. .7
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by CL.-f gyp—,,t,•— (name of person sending permit)
Signature ‘..,4 __.---e 5r--- Date/Time
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 yowlease ttake a few momentts tto complette our custtomer service survey aft
http://www.surveymonkey.com/s/EHCusttomerService
ehpennit 09/21/2023 05:25
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