HomeMy WebLinkAboutLSSP-06-2021-151851.TIF State of NC LSS Permit Option COVID-19 LHD Reference: ldssQ- 0 C 2A)2.1- 151 S5 I
I
PART 3; Authorization to Operate(ATO)
fioept for aatee racalee4 the laden below ie to be cowhand ay the Omer.
LHD USE ONLY: Initial submittal of request for ATO received: /0—b 1 4 by gp
Date Initials
Date of Post-construction Conference:
The fol owing 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 Yes ❑ No !
b. Drawings,specifications,plans rbili-�Yes ❑ No I
c. Reports on special inspections and final Inspection u Yes ❑ No i
d. Management Program manual,Including ORC contract,when applicable r❑r�f�Yes ❑ No
e. On-site Wastewater Contractor's signed statement u-'Yes ❑ No 1
2. Fee(as applicable) Yes ❑ No
3. No Garized letter documenting Owner's acceptance of the system from the LS5 Yes ❑ No i
4. 4.On-site Wastewater Contractor name: Vy1cf--,3P> \ l".104e Y ?Gq V...-Oj'dense number: \C .S..---.4.:. 1
Ma ling address: I `' ' K \\ c'i. City: - _ l _State: Zip:; ,XSe ;
Telephone number: "4Ci ^'1(y E-mail Address: _
e
5. Proo of Errors and Omissions or other appropriate liability Insurance for the On-site Wastewater Contractor is 1
ate ched and includes the name of the Insurer,name of the insured,and the effective dates of coverage.
es ❑ No
Attestation the Owner for Authorization to Operate i
I, 0 A.\( � hereby attest that all Items Indicated above have been provided to the
Print name of Owner
C`( County 1110 aaa d t system shall meet applicable federal,State,and local laws, x
regulations, and or nee
Signvhne of owner Dote y.
This section for[HD Use Only.
•
LHD Rraew of required Information for the ATO
❑INCOviPLETE
Based upon review of information submitted by the Owner in the Section above,the following items are missing I.
from the Information required for an Authorization to Operate for an LS5 COVID-19 permit: „ t'
Copies of this signed form were sent to the LSS and the Owner on ___via
Dote Erna,FAX,LISPS,Hand-degvered
Print rto(ne of ortlsart2ed Agent of the[HO Signature of outJsortaed Agent of the[HD Dolt
COMPLETE
Based upon review of Information submitted by the Owner in the Section above,this Authorization to Operate Is t
hereby issued in accordance with G.S.130A-336.2(m). - `` i
A copy Of this complete NOI/ATO with tracking information was sent to the State on `( t Jig U i(
(t b J l U- P id c r- .�/f��r , illy- Doe bno4 FAX.UYx Ibnd-daNned
Print name of authorized Agent of the l HD Signature of authorized Agent of the l HD Dane ;
;
SSUANCE Dr CERTiFIC4 TE 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 pubac assembly pursuant to GS.130A-339.
DHHS/Efi/05WPB—LS5 COVID-19 COMMON FORM Effective May 5,2020 Page 6 of 6
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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)
County C qr��H b
LHD Reference Number LSS1',/�—0G—ze l —i5 i p ,r f
Permitting backlog as of date of NOI submittal(#days) hvr nRT T
Number of days to process the NOI(#days) r G by
Number of days to process re-submitted NOI(#days or
"NA") II n
Facility type 3;nf 6- /kflt,11 rP-J)al _
Domestic,High Strength or IPWW Do rr1 -j L
Design Daily Flow 360 J
Residential or Commercial ic.ri 6n tJ4l
System type(per Rule.1961) q
Date of Post-construction conference (0—6-24
Date Authorization to Operate issued 10_(2.-2(
Fee charged for LSS COVID-19 D
Is fee sufficient to cover LHD costs? !/
iRT
Date LHD notified of LSS COVID-19 malfunction
Date LHD notified of Owner complaint
Appendix A- Page 4 of 4
DHHS/EHS/OSWPB -September 8, 2020