HomeMy WebLinkAboutWELL-6-11-18793.TIF From: John Beane Fax: +t (88B) 316-3879 To: Tina Propst Fax: +1 (828) 465-8276 Page 1 of 1 6/10/2011 1027
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�:Pu61ic Heslth Dcp�rirnent -- . -- - - - --- - -..-_.._._ .
, Q= Envirvnas�rttal NcalthDlvision 5ubdivi5ion
PO Box 389, (00-A Souc6wtst�ivd 1VCwtot��'C 28658 Lof f� t
p• PIN# 369604921373
Ap�lleanttOwrter BRIE BE.AI�IE
Site qddress: 3094 MATCIE WADE RD, Shcrrills Ford, NC
Property_ Sfze: SF 4.iZQ ACRES
Direat�ans: HOPEWELi. CHLJRCH RD TO MA7'I7� WADE, pROPL'RTY ON LE�I' PAST POWERLiNE
OwnerlAuthorized Represent�tive Acknowledgement of Permit Receipt
� I certify that I am the ov+�er or aut�arized agent (owner's autf�orization required) representic�g the owner of the
property descri5ed above,
� A�s the �raperty owner or authorized represeatative, I have received t�►e above xeferenced �ermit(s) as
equested u� the �pp]ication for service E�IPR 6-11-11090 , b� the fol�owing met�iod($):
Received in Person
^ Facsimile Transinittal {�2etum form with signature required)
� Elecfironic Image Tmrismi#taU E-mail (ReYuan receipt rec�uized)
� As the property owner or authorizec� representahve I have reviewed and undentand the specific
co�ditions of the permit issued, and further understand that all appl�cable regulatory requirements
specified unde�r the Narth Caro�ina Laws and Rrtles for Sewage Treafinent and bisposal SysEems (15A
NCAC 18A .1900), andlor We11 Construction Standards (�SA. i�iCAC 2C .0100), shali apply ta the
issuance of this permi� and the cons�ction of the wastewater system and/or water supply well perrnittet�.
�'ernut �ssue Date: 46I1 �/201 �
t�wncdAuthorize� Representative Signateire �
Date U/ r ( v ' � `
Doeu�entatioa of �'�rmit(s) Trausmittal
(pQrmit trxnsmitted by electronic or other meaas)
�'e�it transmitted by ' � (nr�me of person sending permitJ
Signature ' D�te/Time . �Q �Y yy�
Method: Faac Email U5 N�'�il Other
Qwner's request to send by the above ittdicated met�od of transtnittal ia lieu of signahrre
ack�awlcdges fhe conditioas und statemeats $�ove. �
o��ati oa:3o