HomeMy WebLinkAboutIMPV-01-2021-144378.tif (di:1)
catawba county
public health
VOLUNTARY RELINQUISHMENT OF ADMINISTRATIVE APPEAL RIGHTS
Date prepared: .May.3.2.022
Owner(s): Christopher Kitchens
Mailing Address: 138 Village Club Drive_Apt 111. —
Mooresville,NC 28117
Property location/site legal description: 5556 Little ParkwayT__.___.
PIN: 368700295.6 —
Improvement Permit(IP) 01-2021-144378 Date Issued 01/27/2021
I, 69 (Ig /::it�jc?�'vlil el :voluntarily relinquish my rights to pursue a formal appeal through the North
(pn full name)
Carolina Office of Administrative Hearings pursuant to NC General Statute 130A-24 and 150B-23 and all other applicable
provisions of Chapter 150B for the above referenced permit(s)(which includes the IPs and ACs)in order for the authorized
agent/local health department to issue the applicable permit(new IP and/or AC)for the site. I understand by completing this form
that the permit(s)for a
drip irrigation CIVa)
(System description)
will be revoked immediately by the authorized agent/local health department.
1 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 IF'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. 1 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 relinqui h my a cal rig is but that thi is n option available to me so I do not have to wail 30
days for the revocation of the permit tot ff-
f
Signature of Property Owner. - 'L
r <�
Date Signed: l4, ,isr .01
NCDHHS/DPH/EH5/OSWP Revised May 2015
catawbacountync.gov
Environmental Health
(utowbu County Goveir,ment (enter
25 Government Drive I PO Box 389 I Newton NC 28658 1828.465.82/0
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