HomeMy WebLinkAboutLSSP-06-2021-151861.TIF •
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State of NC
US Permit Option COVID 19 LHD Reference: � p (2� 15lX fD I
PART/i Authorization to Operate(ATO) U
LHDLLSEONLY: Initial wbmhtalof PMe4AU SamOors�rato� ter�aW request for ATO rt ccived_ -Z by
Late initials
Date of Post-constriction Conference:
The f lowing Items are included in this submittal for an Authorization to Operate under an LSS COVID-19 permit:
1. SI fined and sealed copy of the LSS's report that Includes:
a. Signed and sealed evaluation of soil conditions and site features
Erb. Drawings,specifications,plans Yes ❑ No
Yes 0 No
c. Reports on special Inspections and final Inspection
d. Management Program manual,including ORC contract.,when applicable Yes ❑ No
Yes ❑ No
e. On-site Wastewater Contractor's signed statement
2. Fee(as applicable) Yes No
3. Notarized letter documenting Owner's acceptance of the system from the LSS Yes ❑9 No
Yes No
4. 4. On-site Wastewater Contractor name:
J license number: ir)�• w
Mc iling address: ,' - tka b \\ City: �`t`� ``:
�J�� State��� 21p:��S.j 6
Telephone number: .. ``:1%Ls '1(c — E-mail Address:
5.Proof of Errors and Omissions or other appropriate liability insurance for the On-site Wastewater Contractor is
attiched and includes the name of the Insurer,name of the Insured,and the effective dates of coverage.
Oti res ❑No
c
AttatstaKton by the` Owner for Authorization to Operate
I, �"V,v, Ll-k_ hereby attest that all Items Indicated above have been provided to the
Print name 5offOOwner
G �!-�� Countynd the system shall meet applicable federal,State,and local laws,
regulations and rancie2/..._.--
j
S�wtureofOwner \ ',
Lore
This suction for ttl0 Use Only.
LHD Review of required Information for the AM
❑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 EmoIL FAX USPS,Hand-dNMe ed
P/tnr manor of authorized Agent of the LHD
Signature of authorized Agent of the LHD
Date manormanor
COMP,CTE
Based upgn review of information submitted by the Owner In the Section above,this Authorization to Operate Is
hereby Isi ued 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 I ' 1 Li via a
' IZwtq,'
,a o )L ( fir Aiiil fileDate fmat FAX us►S,r entIdeAvered
Print name of«a "hor Agent of the uID (0 (Z'Z
Signature of authorized Agent of the UV Date
ISSUANCE OF CERTIFICATE OF OCCUPANCY:Once the IND determines completeness based upon the ATO submission,the owner may apply to the
local pennkt ng agency for permanent electrical service to a residence,place of business or place of public assembly pursuant to G.S.130A-339.
04IH5/ENS LSWPB-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)
County C0.1-44-4�i
LHD Reference Number L.31,_ (fib—Zon— IS" 86 (
Permitting backlog as of date of NOI submittal(#days) 3 D 110 b tisittov r GYa y,-
Number of days to process the NOI(#days) I day
Number of days to process re-submitted NOI(#days or
"NA") NA
/J
Facility type Y J- l-a in f i d M cJ_
Domestic,High Strength or IPWW PO yhJ2.4,L
Design Daily Flow `)6a
Residential or Commercial )24 tin
System type(per Rule.1961) rIT
Date of Post-construction conference 10
Date Authorization to Operate issued l p-12--2(
Fee charged for LSS COVID-19 q Q
Is fee sufficient to cover LHD costs?
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