HomeMy WebLinkAboutIMPV-9-11-21456.TIF :;5A A, CASHVV BA COUNTY Case#
Tfit*nG,Public Health Department
Environmental Health Division Subdivision
PO Box 389, 100-A Southwest Blvd,Newton.NC 28658 Lot N
18.2 w PIN# 372007688158
Applicant/Owner JOHN BAUER
Site Address: 2273 SETTLEMYRE BRIDGE RD.Newton,NC
Property Size: SF 34_11 ACRES
Directions: STARTOWN RD TURN LEFT ONTO SETTLEMYRE BRIDGE RD 4TH DRIVE ON RIGHT FOLLOW DRIVE ABOUT 300
YDS OFF RD TO HOUSE.
Owner/Authorized Representative Acknowledgement of Permit Receipt
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-9-11-12383 , 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), shall apply to the
issuance of this permit and the construction of the wastewater system and/or water supply well permitted.
Permit Issue Date: 09/14/2011 4-
Owner/Authorized Representative Signature �Gil / %b�eq,
Date p dt_ '7 2D/40
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/Time
Method: 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.
09/I5/I 1 10:46