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Home My WebLink AboutWELL-3-10-5451.TIF PR -2- /D- q032 4Z'~9 Lec Q 1-,G Rd. ~(herc. 15 ar eXl4i av\ a roX. I~X`~g~. c~ro.VLI br,~ S~S~e~• ~^G ~ ~ ~Q I~Z OSed 6vdev {o (OPAVetnsa-Ie: -1ke. lbw -From P1D~" 3 WvM yvk InavSe- , qh J Wi 6W I . o a5 d uc n'`t. v5 i+^5-}a ~ d. 3, brow. -{fie- Icvik +6 -tke e~ClS~rnL oaqc( 6,J,jk 5 hca l~ NO. W`1 ~e. I Asiateed. 5 w Zn5A4 q r,E-t.s . A) (nod S~1°"'" I~~ . ©~DX~ ~ ~,~t,~, ~ Therc i 5 an exi s'f►n~ o ~rd anj~et4 px►~{j:~ r~~~~ ~1-5 a r~p 11 ~--~a~gdon3, ~ W raVi'~ fug` ~e, VJeI~ Shbwr hcr~ CaPP S~ Yefno;►~ a hL -~roM -}he- road w~l i rr u}~ h~ ne\A 1 ► be used -for, connec~cd o °J ~ ~ ao,~ w ~ l b ProPosej C ~ 3}~° a~ yoxbo b Z • TanK 50' ell y~ R ;r --i 31q, - ~iroih ar. v~ 15 TA r° !C. 50 A aft. ~ jade, c ~ o ~ i ~veMsg~s a~ red t ~ a ~rca . n5 ~ S~Lw~ on Con uy y $A AUTH-3-10-5450 IMPV-3-10-5448 WELL-3-10-5451 RONALD BRAIM 1842 sM 4249 LEE CLINE RD, CONOVER Owner/Authorized Representative Acknowledgement of Permit Receipt ~I certify that I am the owner or authorized agent (owner's authorization required) representing the owner of the property described above. //Aff As the property owner or authorized representative, I have received the above referenced permit(s) as requested in the application for service EHPR-2-10-4032 , 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 (j5 l0 Owner/Authorized Representative Signature Date f- jk_/r 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.