HomeMy WebLinkAboutAUTH-3-11-15881.TIF X ; , ruvuc nwMui In n
yaunu Subdivision
r Environmenud Health Division
Po Box 380, I00-A Southwest Blvd, Newton, NC I8658 Lot 4
‘rittr. 169904517576
A ppllcanUOwner MARSHALL HAROLD NAIL
Site Address: 5545 w NC 10 HWY, Hickory, NC
Property Size: SF In/ ACRES
Directions; HWY 10 W, ON LEFT JUST BEFORE WHITENER RD
Owner /Authorized Representative Acknowledgement of Permit Receipt
X ;, ik 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 EHPR -3 -11 -9669 , 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 1 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: 03/08/2011
Owner /Authorized Representative Signature r' � >.- •_ • - '_" -' �. �. C /� � ,, -.
Date ;I
--- - - - - -- --- - - - - -- . ...0110... - -----
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by L, \\,1 ‘ .1 (name of person sending permit)
Signatur. • .i � , - 1 *A& Date/Time \q 1 3o" C 50 0.n-)
Method: X Fax Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
acknowledges the conditions and statements above.
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