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Home My WebLink AboutLSSP-06-2021-151857.TIF State of NC LSS Permit Option COVID-19 LHD Reference: LSS P-- 0 6-2021-I5 I DS7 PART 3: Authorization to Operate(ATO) Except for dote received,the Section below is b completed by the Owner. LHD USE ONLY: Initial submittal of request for ATO received: $�SV-- by tA. D to Initials Date of Post-construction Conference: 'j5 I'L2 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 [� /Yes ❑ No b. Drawings,specifications,plans g Yes ❑ No c. Reports on special inspections and final inspection Yes ❑ No d. Management Program manual,including ORC contract,when applicable Yes ❑ No e. On-site Wastewater Contractor's signed statement Yes ❑ No 2. Fee(as applicable) Yes No 3. Notarized letter documenting Owner's acceptance of the system from the LSS Yes ❑❑ No 4. 4. On-site Wastewater Contractor name: Masten Cloer Backhoe Servicglicense number:10551 Mailing address: PO Box 1128 City:Hudson State: NC Zip:28638 Telephone number: 828-496-7643 E-mail Address: dwguy@yahoo.com S. 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. EYes ❑ No Attestation by the Owner for Authorization to Operate I, ' SOl-A) A. gi_r48.6 hereby attest that all items indicated above have been provided to the Print name of Owner G'4 `.14 Qf County LHD and the system shall meet applicable federal,State,and local laws, regulation , and in e ._ Signature of Owner Date 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 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). q A copyKt9,4e,0 0f this complete NOI/ATO with tracking inf•rmation was s nt tot S eon U 1g1� via PhAtu 1 . Ktigi C/ I/ Dote Email,FAX,USPPS H_a_nd-iZered IC Print naf authorized Agent of the LHD Signat - ,f 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/EHS/OSWPB—LSS COVID-19 COMMON FORM Effective May 5,2020 Page 6 of 6 L55 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 LS5 COVID-19 permitting process. Tracking information for LSS COVID-19 permits (Required) County I a-laa1bq LHD Reference Number (3$f DL_ 2D2(- i5I$57 Permitting backlog as of date of NOI submittal(#days) 35 ,Jli Number of days to process the NOI(#days) I Oy Number of days to process re-submitted NOI(#days or ] "NA,.) N A Facility type 3 Btdro... tiouse Domestic,High Strength or IPWW p0Mc5AiL Design Daily Flow i=1 Residential or Commercial 4ic, System type(per Rule.1961) Date of Post-construction conference S 1 5 z2, Date Authorization to Operate issued g Is I22,„ Fee charged for LSS COVID-19 At 5 $q 0." Is fee sufficient to cover LHD costs? ‘115 Date LHD notified of LSS COVID-19 malfunction Date LHD notified of Owner complaint DHHS/ENS/OSWP—COVID-19 Appendix A Updated February 2022 Page 4 of 4 To: C rA County Department of Public Health Re: Signed Statement of Verificatn of Installed Septic System at Address: 21 S C `2. `1 ft, fl-v . llJ, 14 c.& ,—( rjC , 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 pr en notarized w Owner Signature: Date -7 /-2 7/2-2 North Carolina GL County I, gOt if4 ti w,t h (4, v a Notary Public for( 7a.0194,County, North Carolina, do Hereby certify that —10 0- . (1 personally appeared before me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal, this the 78 — day of v►A Ofpcg • F,Q - Notary public. it,r • pTAR�. -E� �•+ ,oty = My commission expires: . / v004 _ .9 ),_4g-A .1 a`gD c. . `j( a' L.Q \/ \ i-kt . ‘,)\' , C- tr-irt- -#0� ti6 M 03 71 e r ' / .gyp , " , F {. � 4 �i� a.•.' 7 0 3N. 'g yet :. CD CO I i Z — ) 4.04 aw /q, 4 Z tr , i J P4612424, .' • ' , -, / /:::: Ilir 0 . 0 * to : ' .:f-v Cr I >®t 5 13 r 1 --.4 Li 4sd 59 I eft —_____________ CJL54A--A \-\\) \t‘ .-- f\$ . S `` u 'S ' N‘. 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(les)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 EDMOND MASTEN CLOER CERTIFICATE EARTHWISE DESIGNS NAME AND DBA MASTEN CLOER BACKHOE SERVICE HOLDER 991 DUNCAN RD ADDRESS PO BOX 1128 RUTHERFORDTON, NC 28139 HUDSON, NC 28638 COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD 1 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- x TYPE OF INSURANCE AWL SUER POLICY NUMBER POLICYEFF POUCYEXP LIMITS INSO wvD tEl COMMERCIAL GENERAL LIABILITY GL 0445050 08/01/2021 08/01/2022 GENERAL AGGREGATE $1,000,000 AL OCCURRENCE PRODUCTS COMPIOPS AGGREGATE $0 GEN'L AGGREGATE APPLIES PER POLICY 08/01/2022 08/01/2023 PERSONAL&ADV INJURY $1,000,000 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED $100000 PREMISES(Ea Occ rnroel MED EXP(Any one person) $5,000 ❑ EACH OCCURRENCE $ BUSINESSOWNERS AGGREGATE $ COMBINED SINGI E LIMIT $300,000 AUTOMOBILE LIABILITY (Each accident) BAP 2090260 08101/2021 08/01/2022 BODILY INJURY(Par penon) $ SCHEDULED AUTOS ❑ HIRED AUTOS 08/01/2022 08/01/2023 BODILY INJURY(Per accident) $ OERTY ❑ NON-OWNED AUTOS (PPerr ecclKentt DAMAGE $ ❑ GARAGE LIABILITY 0 (Other) EACH OCCURRENCE $ ❑ EXCESS LIABILITY— . OCCURRENCE AGGREGATE $ WC STATUTORY LIMITS S COMPENSATION NIA AND I AND EMPLOYERS'LIABILITY WC 0224922 01/14/2022 01/14/2023 E.L.EACH ACCIDENT $100,000 E.L.DISEASE-EA EMPLOYEE $100,000 POLICY APPLIES TO THE WORKERS COMPENSATION LAW IN THE STATE OF NC I C L DISEASE-POLICY LIMIT $500,000 OTHER: DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED AUTHORIZED REPRESENTATIVE BEE HE EXPIRATION RAN DATE WI THEREOF, NOTICE PRO PROVISIONS. . DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. DATE 07/25/2022 COI 0910