HomeMy WebLinkAboutAUTH-10-2023-207549.TIF 4
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CATAWBA COUNTY
iPublic Health Department Subdivision
_ "I Environmental Health Division PIN# 366602562130
PO Box 389,25 Government Drive,Newton,NC 28658LOT# PT 3
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Site Address: 4745 CREEKSIDE WAY, MAIDEN NC 28650
Name on Permit: MARK HATFIELD
Property Size: Acres 9.61
Directions: Hwy 16 to Buffalo Shoals Rd,turn Right go to East Maiden Turn Left 1 mile, Turn on Creekside Way... across
the creek
Owner/Authorized Representative Acknowledgement of Permit Receipt
A
', I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
AAs the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service RBPR-08-2023-45353,by the following method(s):
Received in Person
Eacsimile Transmittal (Return form with signature required)
lectronic Image Transmittal/E-mail (Return receipt required)
X 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(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: 10/31/2023
Owner/Authorized Representative Signature
Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by ___ (name of person sending permit)
Signature Sp Date/Time I1/��/23
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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 yoiPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService T
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ellper it 11/01/2023 13:41