HomeMy WebLinkAboutIMPV-08-2020-137193.TIF catawba county
public health
VOLUNTARY RELINQUISHMENT OF ADMINISTRATIVE APPEAL RIGHTS
Date prepared: November 23.2022
Owner(s): Nest Homes.l.LC
Mailing Address: PO Box 3965
Cornelius,NC 28031
Property location/site'legal description: 3159 Timber Run Ln
FIN: 367804626568
Improvement� __,A� Permit(IP) 8-2020-137193 Date Issued .8/1.S/21Y0
I, 04 [ y VASE N(,voluntarily relinquish my rights to pursue a formal appeal through the North
(print full name)
Carolina Office of Administrative Hearings pursuant to NC General Statute I30A-24 and 150B-23 and all other applicable
provisions of Chapter 150B for the above referenced permits)(which includes the IPs and ACs)in order for the authorized
agent/Iocal health department to issue the applicable permit(new 1P and/or AC)for the site. I understand by completing this form
that the permit(s)for a
25%reduction_system(Ilig)
(System description)
will be revoked immediately by the authorized agent/local health department.
I understand that the local health department's revocation of a permit can be appealed to the North Carolina Office of Administrative
Hearings within 30 days of the revocation pursuant to the North Carolina Administrative Procedure Act. I understand that in order for
the local health department to issue another IP and AC that the current IP and AC must be revoked. I understand that the local health
department's revocation of an IP or CA is not effective until 30 days from the revocation or, if the revocation is appealed,at the time
that the Office of Administrative Hearings issues a final decision. I understand that by signing this form and relinquishing my right to
appeal the permit revocation at the Office of Administrative Hearings that the local health department's permit revocation will become
effective immediately. I understand and agree that the revocation of a permit that takes effect immediately is in my best interest. I
understand that by signing this form that I agree that I do not want to appeal the permit revocation.
I understand that I am not required to relinquish my appeal rights but that this is an option available to me so I do not have to wait 30
days for the revocation of the permit to take effect.
Signature of Property Owner:
Date Signed: 1 a / L !p2 �_
NCDHHS/DPH/EHS/OSWP Revised May 2015
catawbacountync.gov
Environmental Health
Catawba County Government Center
25 Government Drive I PO Box 389 Newton NC 28658 1828.465.8270
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