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HomeMy WebLinkAboutLSSP-07-2020-136369.tif LSSR-07,c)o io-I36)369 i ' pPPO7 )Cld1. 3)3) 3 tia;,STA7Fu.H0, R31 Dorse4 WA, Conoue,r . , p'i ROY COOPER • Governor `gin ,- NC DEPARTMENT OF It - i; HEALTH AND MANDY COHEN, MD,MPH • Secretary °����� R. HUMAN SERVICES�Y� 4�, a=; MARK T BENTON • Assistant Secretary for Public Health -- Division of Public Health COMMON FORM FOR LICENSED SOIL SCIENTIST COVID-19 PERMIT OPTION FOR NON-ENGINEERED SYSTEMS See Instructions for Use in Appendix A Except for"Date received",this Section to be completed by the L55 fn accordance with 5 L 2020-3,Section 4 18 and G S 130A-336 2 ``nn LHD USE ONLY Initial submittal of this NOt received 7/30/2020 by 1"� _ Dote inldah • PART 1 Notice of Intent to Construct(N01) II New ❑Expansion -. " ❑ Repair—LHO Permit Number E Repair—EOP/LSS Permit Number 1 Facility Owner's name (Owner,Company Name,Utility, Partnership,Individual,etc) �J. Jeremy Petty Mailing address POP Box 1170 City Newton State -NC Zip 28658 Telephone number 828)320-1477 E-mail Address jeremyCiprintimage corn 2 Licensed Soil Scientist(LSS)name Caroline J Edwards LSS License number 1220 Mailing address 991 Duncan Rd City Rutherfordton State NC Zip 28139 Telephone number 828)289-0122 E-mail Address ciedwards234PRmail corn 3 Licensed Geologist{LG)(if applicable)name NA License Number Mailing address City State Zip _• Telephone number E-mail Address 4 Proof of Errors and Omissions or other appropriate liability Insurance for the following persons is attached that includes the name of the insurer, name of the insured and the effective dates of coverage ® LSS ❑ LG S Property location(physical address,tax parcel identification number or subdivision lot,block number of the property to be permitted) 6639 Dorsett Lane Conover NC 6 County Name Catawba 7 Type of facility NM Place of residence No Bedrooms 3 No Occupants^2_ 0 Place of business Basis for flow calculation 0 Place of public assembly Basis for flow calculation NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH LOCATioN 5605 Six Forks Road Raleigh NC 27609 MAILING ADDRESS 1642 Mail Service Center Raleigh,NC 27699-1642 www ncdhhs gov • TEL 919-707-5854 • FAX 919-845-3972 AN EQUAL OPPORTUNITY f AFFIRMATIVE ACTION EMPLOYER r i State of NC LSS Permit Option COVID-19 LHD Reference LSSP-07-2020-136369 8 Factors that would affect the wastewater load None 9 Type,location,and classification(per Rule 1961)of wastewater system _Residen ial SFH.drain field to left of house site from road.Type Ille Site previously permitted,change to LSS OP 10 Design wastewater flow 360 gpd Design wastewater strength MI domestic ❑high strength ❑Industrial process(For hrgh strength and industrial process wastewater,a Professional Engineer licensed in accordance with G S 89C shall design the on site wastewater system) 11 A plat as defined in G S 130A-334(7a)is attached ❑Yes [2No 12 A site plan as defined in G S 130A-334(13a)is attached iUu Yes ❑ No In accordance with G S 130A-335(f),an LSS COVID-19 Permit with a plat is valid without expiration and an LSS COVID-19 Permit with a site plan is valid for flue years 13 Owner meets requirements of ownership or control of the system per 15A NCAC 18A 1938(j) Yes® No❑ 14 Easement,right of way or encroachment agreement required per 15A NCAC 18A 19380) Yes❑ No if yes,documentation filed In County Register of Deeds In Deed book Page 15 Multi-party agreements required,as applicable,pursuant to 15A NCAC 18A 1937(h) ❑Yes Q No If yes,agreements filed in County Register of Deeds in Deed book Page 16 Location of proposed or existing wells(drinking water,Irrigation,geothermal,groundwater monitoring,sampling,etc) and any potable and non-potable water conveyance lines is indicated on attached plans and complies with 15A NCAC 18A 1950 x❑Yes ❑ No This Is a saprolite system 0 Yes El No 17 Evaluation(s)of soil conditions and site features In accordance with G 5 130A-335(a1)signed and sealed by a L55 is attached xJYes ❑No 18 Evaluation of geologic and hydrogeologic conditions signed and seated by a LG is attached ❑Yes © NA 19 Proposed landscape,site, drainage,or soil modifications are attached U Yes II NA Attestation by LSS pursuant to S.L.2020-3,Section 418 and G S 130A-336 2 I, Caroline J Edwards hereby attest that the Information required to be included with Licensed Soil Scientist(Print Name) this Notice of Intent to Construct is accurate and complete to the best of my knowledge and that the proposed system shall meet applicable federal,State,and local laws,regulations,rules and ordinances,and that the proposed system does not require a Professional Engineer,licensed In accordance with G 5 89C,and In accordance with 15A NCAC 18A 1938 and activities determined to be engineering as determined by the North Carolina Board of Examiners for Engineers and Surveyors" CP--)•&k..\:k Z`k e--40 Signature of Licensed Soil Scientist Dote NOTES DHNS/ENS/OSWPB—LSS COVID-19 COMMON FORM Effective May 5,2020 Page 2 of 6 • r ! State of NC L55 Permit Option COVID-19 LHD Reference LSSP-07-2020-136369 NOTES LIABILITY The Department,the Department's authorized agents,or local health departments shall have no liability for wastewater systems designed,constructed,and Installed pursuant to on LSS COVID-19 Permit Option IS L 20203, Section 4 18(d)and G S 130A-336 21 RIGHT OF ENTRY The submittal of this Notice of Intent to Construct grants right of entry to the Local Health Department and the State to the referenced property ISSUANCE OF BUILDING PERMIT Once the LHD deems that the Notice of Intent to Construct is complete via signature in the section below,the owner may apply to the local permitting agency for a permit for electrical, plumbing,heating,air conditioning or other construction,location or relocation activity under any provision of general or special law pursuant to G S 130A-338 OHHS/ENS/OSWPB—LSS COVID-19 COMMON FORM F.ffrctive May 5,2020 Page 3 of 6 State of NC LSS Permit Option COVID-19 LHD Reference LSSP-07-2020-136369 This section for Local Health Department use only PART 2 LHD Completeness Review of the Notice of intent to Construct "(c) Completeness Review for Notice of intent to Construct —The local health deportment shall determine whether the notice of intent to construct required pursuant to subsection(b)of this section Is complete within five business days after receiving the notice of intent to construct A determination of completeness means that the notice of Intent to construct includes ail of the required components if the local health deportment determines that the notice of intent to construct is incomplete, the local health department shall notify the owner and list the information needed to complete the notice The owner may then submit additional Information to the local health deportment to cure the deficiencies in the initial notice The local health department shall make a final determination as to whether the notice of Intent to construct Is complete within five business days after the deportment receives the additional information if the local health deportment foils to act within any time period set out In this subsection,the owner may treat the failure to act as a determination of completeness The owner shall be able to apply for the building permit for the project upon the decision of completeness of the notice of intent by the local health department or if the local health department falls to act within the five business day time period" The review for completeness of this Notice of Intent was conducted In accordance with G S 130A-336 2(c) This NOI is determined to be ❑ INCOMPLETE(If box is checked, Information in this section is required ) Based upon review of information submitted in Part 1,the following items are missing Copies of this form listing missing items were sent to the LSS and the Owner on Dote via with directions to re-submit missing items using Page 5 of this form Email,FAX,LISPS,hand delivered Print Name of Authorized Agent of the LHD Signature of Authorised Agent of the LHD Date ® COMPLETE(If box is checked,information in this section is required ) Based upon review of information submitted in Part 1 of this form,this NOI is deemed COMPLETE Copies of this signed form were sent to the LSS and the Owner on 7/31/20 via email Date Email,FAX,LISPS,hand delivered A copy of this NOI and tracking information was sent to the State on via Date Email,FAX,LISPS hand-delivered i\AMegen McBride 14` 7/31/20 Print Name ofAuthorrzedA Agent ofthe LHD S natu Authorised Agent ofthe CND Date 9 � f g DNHS/EHS/OSwPR—LSS COV/D-19 COMMON FORM Effective May 5,2020 Page 4 of 6 • State of NC US Permit Option COVID-19 LHD Reference LSSP-07-2020-136369 Re-submittal of NOI with missing items included Thus Section is for use by owner to submit Items noted as missing dung LHD Completeness Review above Resubmittols must be accompanied by a cover letter from the LSS LHD USE ONLY This NO! resubmittal received by Date Initials Item If from Initial NOI Resubmittal description - Attestation by LSS pursuant to S L.2020-3,Section 418 I, hereby attest that the information required to be included with Licensed Soil Scientist(Print Name) this Notice of Intent to Construct Is accurate and complete to the best of my knowledge and that the proposed system shall meet applicable federal,State,and local laws,regulations,rules,and ordinances Signature of Licensed Sod Scientist Date The section below Is for Local Health Department use after submittal of Items noted as missing above LHD Follow-up Completeness Review of Notice of intent to Construct This follow-up review for completeness of this Notice and Intent was conducted in accordance with G S 130A336 2(c) This NOI is determined to be ❑INCOMPLETE Based upon review of information in the RESUBMITTAL above,this Notice of Intent remains INCOMPETE because the following items from Part 1 of this form remain missing Copies of this signed form were sent to the LSS and the Owner on via Dote Email FAX,USPS Hand delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Dote ❑COMPLETE Based upon review of information submitted In the RESUBMITTAL above in addition to information provided in Part 1 of this form,this NOI is deemed complete Copies of this signed form were sent to the LSS and the Owner on via Dote Email,FAX,LISPS Hand delivered A complete copy of this form with tracking information was sent to the State via Date Email,FAX,USPS,hand delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Dare DHHS/EHS/OSWPB—LSS COV1D-19 COMMON FORM Effective May 5, 2020 Page 5 of 6 State of NC LSS Permit Option COVID-19 LHD Reference: t'-W 07- 20z0- Ls'636 j' PART 3: Authorization to Operate(ATO) Except for date received,the Section below i to be completed by the Owner. LHD USE ONLY: Initial submittal of request for ATO received: LI tll 'j,'1 by Sf rialtc-i,s, Initials Date of Post-construction Conference: The following items are included in this submittal for an Authorization to Operate under an LSS COVID-19 permit: 1. Signed and sealed copy of the LSS's report that includes: a. Signed and sealed evaluation of soil conditions and site features Z . Yes ❑ No b. Drawings,specifications,plans 2 Yes ❑ No c. Reports on special inspections and final inspection 0: Yes ❑ No d. Management Program manual,including ORC contract,when applicable 0 Yes ❑ No e. On-site Wastewater Contractor's signed statement 0: Yes ❑ No 2. Fee(as applicable) 0/Yes ❑ No 3. Notarized letter documenting Owner's acceptance of the system from the LSS Yes ❑ No 4. 4. On-site Wastewater Contractor name:eDt 1 \K T"ys 'e tDS i nse number: I.Q c q I Mailing address: 1� -S' \\Lily pith tOS Ctv-cccity: Cov'O'.Uj\ State: V\C..._ lZip:, \3 Telephone number: -, Z 17421 E-mail Address: 4-1`S�v\�(`cu,\co, \CJv 1• Lig VW 5. Proof of Errors and Omissions or other appropriate liability insurance for the On-site Wastewater Contractor is attached and includes the name of the insurer,name of the insured,and the effective dates of coverage. 0Yes ❑ No Attestation by the Owner for Authorization to Operate I, : ' v'42 r.^l '� hereby attest that all items indicated above have been provided to the Print name of ner 11111 County LHD and the system shall meet applicable federal,State,and local laws, regulations, rules and ordi i 71.„ Sig r ure of Owner D to This section for LHD Use Only. LHD Review of required information for the ATO ❑INCOMPLETE Based upon review of information submitted by the Owner in the Section above,the following items are missing from the information required for an Authorization to Operate for an LSS COVID-19 permit: Copies of this signed form were sent to the LSS and the Owner on via . Date Email,FAX,USPS,Hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Date I COMPLETE Based upon review of information submitted by the Owner in the Section above,this Authorization to Operate is hereby issued in accordance with G.S. 130A-336.2(m). A copy of this complete NOI/ATO with tracking information was sent to the State on 5I 0 L2 via VAGtl . Date mail,FAX,USPS,Hand-delivered s ,,,, �f c e ,} ( Y/4 /7i Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD /Date ISSUANCE OF CERTIFICATE OF OCCUPANCY: Once the LHD determines completeness based upon the ATO submission,the owner may apply to the local permitting agency for permanent electrical service to a residence,place of business or place of public assembly pursuant to G.S.130A-339. DHHS/ENS/OSWPB—LSS COVID-19 COMMON FORM Effective May 5,2020 Page 6 of 6 LSS COVID-19 Permit Option Tracking information The LHD completes this form for each NOI/ATO submitted to their offices. The LHD updates this information and re- sends it throughout the process as appropriate. The Department will use this data to answer any questions on the implementation of the LSS COVID-19 permitting process. Tracking information for LSS COVID-19 permits (Required) LL County CalkK LxO1 LHD Reference Number LSS?-07_ ). OC) - 1%361 Permitting backlog as of date of NOI submittal(#days) 35 Number of days to process the NOI(#days) Number of days to process re-submitted NOI(#days or "NA") A Facility type 3 Vedre vk {-IO\s . Domestic,High Strength or IPWW C mot ft, Design Daily Flow 3bo tycl Residential or Commercial ReSi cr t System type(per Rule.1961) at G Date of Post-construction conference 9 (I 42- Date Authorization to Operate issued 4 122 Fee charged for LSS COVID-19 CG Is fee sufficient to cover LHD costs? Date LHD notified of LSS COVID-19 malfunction Date LHD notified of Owner complaint DHHS/EHS/OSWP—COVID-19 Appendix A Updated February 2022 Page 4 of 4 REVISED 7/28/20 ( Supplemental Site Map: Initial System: Gravity to Illg Initial Septic System Layout 360 gpd/0.45/3x75% =200 ft' 6639 Dorsett Ln Initial Field: 3 lines©68' or W: current well. abandon equivalent. D = D box; Soil PIT 1; Soils Boring locations 2- 5 ST= septic tank C rA Pk\ Graphic Scale p`m4i p 50 ft. ac./.0 s \cr4 t, l � • Lake Hickory ' Initial House Field 2 Building Envelope 68' 68 1 % r • moo' DST 1s° Setbac to 3 Lake �°?•' Hickory /,„cc, � 50 ft. min. Ay- `, F�v eai s. h6 J-Ep -ry!U Earthwise Designs ` >f, TXP '` `' CJEdwards234QmaiLcom Soils & Land Evaluation iaau 828)289-0122 t\-- ' ' Thl,'0 ' t—\ - ?-Z— C___- i 6'(k)..7-cKts\IA-1)(1, _ • Ln PLAN ,IS S M • F4dc iS / I FOR ILLUS Alit ON OY. / / / / PROJECT FOR: ( ( I ( ( // ( ( r JEREMY PERM I • I 1 i 1 / I ` ! I Parcel 74501498690 I U I ( { l Buiyi Envelope I{ �7�77 1.r�.11 SET CIRCLE 11 CONOVER,NC. '' I I 11 \ \\ i t I Catawba County ( I I I 1 i \ 1' \.. Contoct Pierson: • air r� 1 \ soxI TANI \ EarttTwlse Designs 11 ` \ \ Caroline Edwards \ 1 \\ \ \ \ t S1T218UnaN BOX z caedwards234Ogmall.com \ \ \ \ z•sd,.,o PVC \ \ foRCE u,uN \ Dale 4-12-2021 ,as ,t I• \ \ CONTRa \ IP L \ CCESSOR ., \ PANEL UAINGS PUMP Q.£j \ 1 1 \ \ YOH NO 4111P S \liel‘ \ LAWS \ \1 \ \ \\ • \\ \ \ , * ,\ \ \\ \\ `\ \ \ \ \ \ \ \ \ SCALE: " = •s' PUMP: Barnes Solids Pump SE-411 WNO FIR I=I Sfo hp. 15' Cord, 115v, MANUAL. 3—FLOAT SYSTEM, SIMPLEX, NEMA 4X — » 'tri gm al ?Ell 11111IMMID M. a CONTROL PANEL WITH AUDIBLE &VISUAL 1 1 VIM .. I"' ALARMS - msral•- ;«.=; Fibreglass 30" x 48" WITH SOLID 117'14 •- ItiES E I " LID, PUMP IS TO BE WIRED DIRECT TO :• ,z N :::i' . = PANEL (No Junction Box). _ Y 1 FLOATS: 3 FLOAT SYSTEM WITH BRACKET .— .j3,. _ IS. , i•i, -Mil Float Settings • 3 Float Demand System 4— .:o , __.4.,..,.__! Pump "Off" 0 1" above Pump (16"typ.) _ fix•.. Pump "On" 0 24" above "Off" Float p. lit.- Alarm Float 0 4" above "0n" Float '— ! ' W EI_m. 1. Pumps, Tanks, and other products con ,� .:"sns i i , be substitiuted by submitting request to " °" II Al.Y es IIII Engineer for review. --r 2, Contractor may have to add a series of 53gpm 90' bends to control head into tank. `\` r,rr�, �� .,�`'�� . rei i�� LASH a 9• i Ina ENGINEERING SEAL ,�, no4On*CCan•v►Ab 14265 7'z ! U IllU Mu ral.,NC 28t06 Phone 704/8+7 aoo1 iiiIIIIllllll\\ 1 To: Catawba County Department of Public Health Re: Signed Statement of Verification of Installed Septic System 6639 Dorsett Lane Conover NC My signature below hereby attests acceptance of this system from Caroline J. Edwards NC Licensed Soil Scientist #1220 EARTHWISE DESIGNS 991 Duncan Rd Rutherfordton, NC 28139 I submit that this Authorization to Operate (ATO) is accurate and complete to the best of my knowledge and that the constructed system shall meet applicable federal, State, and local laws, regulations, and ordinances. Sign with NOTARY present, notarized low. Owner Signature: _ J �•7,7- (I Date I/ / North Carolina Catawba County '-‘...6 I, I l��C-, a Notary Public for 0 a \\ \1 County, North Carolina, do Hereby certify that194)1/44,(1 personally appeared before me this day and acknowledge he due execution of the foregoing instrument. Witness my hand and official seal, this the \ 0'.\ day of WA \ , 2021. jr/11) ::'.- S%,,,"..5 -Ssion •'9 •, Notary public: i IC SOTARy "_ Y p / "1 ���1 L/2� ,•, PUBUC� ;' v= M commission ex ires: r = •• r, 2: 9 ••a; 17,2o?,„-k. ,, i COUP,.•'°;` `` Installer Name 2sL\1 S ,Q)v-„Ai\ Address: To: Catawba County Department of Public Health Re: Signed Statement of Verification of Installed Septic System Address: lO\,_d My signature below hereby attests that the installation is installed as designed with any as-builts/changes as attached; and I submit that this Authorization to Operate (ATO) is accurate and complete to the best of my knowledge and that the constructed system shall meet applicable federal, State, and local laws, regulations, rules and ordinances. )4421/. Installer Signature: Date (I/- 2c_'_ NORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY, INC. CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), INSURED COOL PARK PUMPING INC CERTIFICATE EARTHVVISE DESIGNS NAME AND 1535 VICTORIAN HILLS CIR HOLDER 991 DUNCAN RD ADDRESS CONOVER NC 28613 RUTHERFORDTON NC 28139 COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICE&LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. X TYPE OF INSURANCE ,AOOL NSDSUBR POLICY NUMBER CMfODiY ff PP OY IC Y XPY} LIMITS El COMMERCIAL GENERAL LIABILITY GL 0471229 11/10/2021 11/10/2022 GENERAL AGGREGATE $1,000,000 _ -OCCURRENCE i PRODUCTS-COMWOPS AGGREGATE $1,000,000 GENII AGGREGATE APPLIES PER POLICY PERSONAL&ADV INJURY $1,000,000 EACH OCCURRENCE S1,000,000 DAMAGE TO RENTED $100,000 PREMISES fEa Oaarten,st • MED EXP(My one person) $5,000 ■ EACH OCCURRENCE $ BUSINESSOWNERS — AGGREGATE $ INC3LE Lear AUTOMOBILE LIABILITY (adac dent) $ ■ SCHEDULED AUTOS BODILY INJURY(Per person) $ • HIRED AUTOS BODILY INJURY(Per sodden') $ • DAMAGE NON-OWNED AUTOS _ ( accident) $ • ■ GARAGE LIABILITY ■ (Other) EACH OCCURRENCE $ ■ EXCESS LIABILITY— _ -- OCCURRENCE AGGREGATE $ WC STATUTORY LMfS ►, :WORKERS COMPENSATION AND EMPLOYERS''LIABILITY NfA. WC 0247457 111/04/2021 11/04/2022 E.L.EACH ACCIDENT $100,000 LIABILITY EL DISEASE-EA EMPLOYEE $100,000 POLICY APPLIES TO THE WORKERS COMPENSATION LAW IN THE STATE OF NC E.L.DISEASE-POLICY LIMIT $500,000 OTHER: ■ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED AUTHORIZED REPRESENTATIVE — BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE ZAC SMITH DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. DATE 03/30/2022 ( -1 COI 0910