HomeMy WebLinkAboutWELL-4-11-17431.TIF 05/02/2011 10;40am #239 Page O1/O1
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CATAWHA COUN'[Y � # �
� § �PubIlc.NeallhDepenment •
Fsvironmental Heplth Div�sloe Subdivision [i L R1SER 1vt11P 2
;PO Box•3�9; 100 Southwe�t Blvd, hewta� NC 28658 Lot# q
y r�� 461604638711
�v��canvOw,ner .SC07""d� HOPKINS
S►ta Addreas: 8�30 HAR80R CCR, TrrrCll, NC
Property Slact: SF � �C�
Direotiona:. l50 E/ KISFK iSLAND RD/ LEFT HARBOUR CiR
�n�r/Authorixec! Repr�sentative Ac�cnowledgertaent of Per�it lteceipt
� 1 certify that 1 am tho owner or authoriud agent (o�mer's auttiori�tion required) represcnting the owner of the
property described abov�,
� As the property owner or authorized representative, ] have-received the a6ove referenced permit(s) as
requested in the application for service EHPR-4=11•10460 , by the following method(s):
Received in Person
Facsimile Tcansnnittal (Return form with signature required)
�/ Electronic fmage Transmitt�t! E-mail (Return receipt required)
As the property owner or authorized representative I hav� reviewed and understand;lhe specific
� conditions of the permit issued, and further understand thRt all applicable regufatory requir�ements
specifie� under the.lYorth Caro[ina I,�ws and Rules for Scwage �'reatmeat.mnd Systems (l.SA
NCAC 18A .R900), and/or Weli C'onstewoction Shrndards (15A NCAC ZC .0100), shall apply to the
issuance of this perniit and the constructiva af the wastewuter system and/or water supply well permittcd.
Permio Issue Date: 04/28/2011
— �OwnerlAuthorized Rep�esentacive Si�nature � _ ' �
Date ,,t���
Documemtetion Permi6(s} Transgnlrtal
(permit transmitted by eleetronic or other means)
pecmit transmitted .by ��_____ ll (name ojpera•vn sending permrf)
Signatwre DatelY'imc q 11 °� a'• 1 O�
11�tetbod: Faa ./ Eneail [!S Mail Other
Owr�cr'� �eyuest to sead by�t�e abave andicated method o( transmittal. in leeu �of s9gnatu�re
eckeiowledges t6e cvaditions and statemcnts above.
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