HomeMy WebLinkAboutAUTH-6-11-18498.TIF HICKi�R''r' CHIROFRHTIC Fa.>:�8���32�<;��h3 7un � 2 011 U�4[J P.O
°�,� � : CATA�VBA COCi?�TY Case � AUTH-6-11-18a93
/�:j } \ P,ublic He�l[h Dcparanrnc Subdi':i5io�
� � .�i Environmcntal Hcslih Division
�`( '" � 4 �j'� PO goz 389, 10(�A Sou�h���cst Bh'd, ;:c��ten. NC 25653 Lec ;�
�;��/ PIT�� �6SfiO4S4285�1
ApplicantlOwncr j�rj�j� �3E,4L
Site Address: 2310 PARKLR RD, Msiden, 1JC
ProperLy Size: SF �.�9a ACRES
Directlons� HIGH�t'AY lb S- TUP.N R1GHT O1dT0 �UF�AI,O SHOALS RU - TURN LEFT QNTO E��S T�4ATDEN F.D -"rt.�F.N
RIGKf ONTO HENLY RD - TAi:E F1RST DIRT RD OI�' R1GNT - l ST !-IOUSE ON R1GHT
Owner/Authorized Representative Acl�r�or��➢cdgement of Permit �teceipt
✓ I certify that I am the owner or authorized agen* (o�Uner's at�thoriZ�tion required) representing the owner oFthe
�roperty described abo��e.
'✓ As the property owner or authorized repr�sentative, 1 have received the above referenced pzrmit(s) as
reeuested in the application for sen�ice EHPR-5-1�-11027 , by the follo��ing znethod(s):
Received in Person
Facsimile Transmittal (Retum form �uith signature required)
� Electronie Ima�e Transmittal/ �-mail (Return receipt required)
�/ As die property o«rner or authorized representative I have revie���ed and understand the specific
conditions ot the permit issued, and further understand that all applicable re,ulatory requirements
specified under the North Carolina Lx�vs and Rules for Se�vage Treatment and Disposal Systems (l5A
NCAC 18A .1900), nndlor ti�Vell Canstruction Standards (15A NCAC 2C .OlUO), shall apply to �11e
issuance of this pernut and the consin.rction of the wastewater systern and'or water supply vvell permitted.
Permi.t Issue Date: 06/Ul/2011 �
O���er/Authorized Representative Signatuze _ '
Date (� - a - j I
-----------------------------------------------------------------------------------------------
Documentation of Percuit(s) Transmittal
� (permit iransmitted by electronic or ofher mean5)
Permit vansmitted (»arr7e o�person sei�a'ir�g perrni!)
Si��nature �LILLL . Date/Time '� I �- �b
vlethod: Fa�c �EmAil US h'Ia"rl Uther
Owner's request to send by the �bove itadicated method of transniittal in lieu of signature
acknu�vledges tlic conditiods and statements above.
S'h e�r� ��� �,e�fY c�,; �o . c'o ►�
o�m,ii i iz:��