HomeMy WebLinkAboutIMPV-11-2023-208384.TIF .$ CATAWBA COUNTY Case# IMPV-1 1-2023-208384
t( iii,,y Public Health Department Subdivision
d - '� Environmental Health Division PIN# 379004734223
lilrPO Box 389,25 Government Drive,Newton,NC 28658 ',aril2
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Site Address: 6755 GOLDIE LN, CATAWBA NC 28609
Name on Permit: WILLIAM&STEPHANIE THOMAS
Property Size: Acres 1.150
Directions: NC 10, right onto Hudson Chapel Rd, right onto Bolton Rd, left onto Goldie Ln
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.
i. As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service EHPR-10-2023-45828,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
IElectronic Image Transmittal/E-mail (Return receipt required)
itAs 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(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: 11/14/2023
Owner/Authorized Representative Signature
Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by _ (name of person sendingQ permit)
Signature e. Date/Time l//?Ol c 13
Method: Fax JEmail 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 aft
http://www.surveymonkey.com/s/EHCusftomerService
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ehpennit 11/17/2023 06:03 i