HomeMy WebLinkAboutIMPV-231211-03.tif i
.ram it„. CATWBA COUNTY Case# IMPV•231 2 1 1-03
1 tine Public Health Department Subdivision MOUNTAIN CREEK RIDGE
;t`i )•. Environmental Health Division PIN# 369803213720
Vie*. PO Box 389.25 Government Dr,Newton,NC 28658 LOT# 28
Site Address: 3027 MOUNTAIN CREEK DR,SHERRILLS FORD,NC 28673
Name on Permit: KURTZ THOMAS,KURTZ KATHARINE
Property Size: Acres 1.44
Directions: NC 16.left onto Buffalo Shoals Rd,right Little Mountain Rd,stay on Little Mountain Rd,left onto
Mountain Creek Dr,property on the left
OwnerlAuthorized Representative Acknowledgement of Permit Receipt
\I 1 certify that I am the owner or authorized agent(owner's authorization required)representing the
owner of the property described above.
s4s the property owner or authorized representative, I have received the above referenced
r)as requested in the application for service IMPV-231211-03,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
Electronic Image Transmittal/E-mail(Return receipt required)
)( 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) hall apply to the
issuance of the permit and the construction of the wastewater system and/o ater supply well permitted.
Permit Issue Date:2023-12-11
Owned uthorized Representative Signatu
Date
Documentation of Pormits(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature .t.P Date/Time 0 40-(9;3
Method: _ Fax Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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Acwnowicagemant 01 Rea.pi I2n 3/2027
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