HomeMy WebLinkAboutEXSY-09-2023-205452.TIF i
4���+yt,' CATAWBA COUNTY Case N EXSY-09-2023-2054S2
tr .' �� Public Health Department Subdivision
ci `s Environmental Health Division PINK 385602564518
;�� PO Box 359,25 Government Drive.Newton,NC 2S65t LOIN
I:Ill ■
SkeAddress: 4558 BUFF PARK RD,MAIDEN NC 28850
Nan.on Parrett 'JOSHUA BUFF
Property Stu: Acres 2.01
Directions: 7th Mobile home on Buff Park Rd,which is on E Maiden Rd
Owner/Authorized Representative Acknowledgement of Permit Receipt
K
ZIA I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
K Sty As the property owner or authorized representative,)have received the above referenced
permit(s)as requested in the application for service RBPR-08-2023-45248,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
7 Electronic Image Transmittal/E-mail (Return receipt required)
(2131, 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(ISA NCAC 18A.1900),
and/or Well Construction Standards(1SA 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:09/2612023
Owner/Authorized Representative Signature 4A.pituaii Ir
Date I0)31Z3
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name ofpersonsending permit)
Signature Date/Time /D/.3//3
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 youPlease flake a few momentts tto complette our ctmtomer service survey att
http://www.surveymonkey.com/s/ENCusttomerService
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