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HomeMy WebLinkAboutLSSP-10-2021-159032.TIF 'i"65 Slone. Or - Lo} 126 Ili l lsi ui e, Ls.re fo _zoLI - lsci0 32 4r�:r \6i' 07- )0)/-31.3Scf •- , , ROY COOPER • Governor , l NC DEPARTMENT OF • . T HEALTH AND MANDY COHEN, MD, MPH • Secretary 3: r HUMAN SERVICES MARK T. BENTON • Assistant Secretary for Public Health Division of Public Health COMMON FORM FOR LICENSED SOIL SCIENTIST COVID-19 PERMIT OPTION FOR NON-ENGINEERED SYSTEMS See Instructions for Use in Appendix A Except for"Date received",this Section to be completed by the LSS in accordance with S.L.2020-97,Section 3.19 and G.S. 130A-336.2 LHD USE ONLY: Initial submittal of this NOI received:____j 0• f-2 I by pp note !mewls RECEIVED PART 1:Notice of Intent to Construct(NOI) • New ❑ Expansion OCT J 2D21 ❑ Repair-LHD Permit Number ❑ Repair-EOP/LSS Permit Number Environmental Health 1. Facility Owner's name: (Owner,Company Name,Utility, Partnership, Individual,etc.): WJH LLC - Century Complete Mailing address: 9325 Center Lake Dr., Suite 160 City: Charlotte State: NC Zip: 28216 Telephone number: 833-791-0192 E-mail Address: katie.dyess@centurycommunities,com 2. Licensed Soil Scientist(LSS)name: Larry Thompson LSS License number: 1287 Mailing address: PO Box 541 City: Midland State: NC Zip: 28107 Telephone number: 704-301-4881 E-mail Address: larry Q@thompsonenv.com 3. Licensed Geologist(LG)(if applicable) name: N/A License Number: Mailing address: City: State: Zip: Telephone number: E-mail Address: 4. Proof of Errors and Omissions or other appropriate liability insurance for the following persons is attached that includes the name of the insurer, name of the insured and the effective dates of coverage: ® LSS ❑ LG S. Property location(physical address,tax parcel identification number or subdivision lot, block number of the property to be permitted): 4856 Stone Drive, Conover, NC 28613 (Lot 126 - Millstone) County Name: Catawba 6. Type of facility: ❑■ Place of residence No. Bedrooms: 4 No. Occupants:8 ❑Place of business Basis for flow calculation: 1-1 Place of public assembly Basis for flow calculation: NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH LOCATION.5605 Srx Forks Road. Raleigh NC 27609 MAILING ADDRESS 1642 Mail Service Center, Raleigh, NC 27699-1642 www.ncdhhs.gov • TEL.919-707-5854 • FAX 919-845-3972 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER State of NC LSS Permit Option COVID-19 LHD Reference: ✓sf I — 0_2°24_/ P O3 L PART 3: Authorization to Operate(ATO) Except for date received,the Section below is to be completed by the Owner. LHD USE ONLY: Initial submittal of request for ATO received: '3-3 0 - 2-Z by 11° Date Initials Date of Post-construction Conference: Fl--1 D -2 L 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 ©Yes ❑ No c. Reports on special inspections and final inspection ❑Yes El No d. Management Program manual ❑x 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. On-site Wastewater Contractor name: Sid Gaskins License number: 1077 Mailing address: 4744 Celia Creek Road City: Lenoir State: NC 21p: 28645 Telephone number: 828-244-9765 E-mail Address: sid@watermanagementnc.net 5. 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. ©Yes ❑ No Attestation by the Owner for Authorization to Operate 1, Century Complete hereby attest that all items indicated above have been provided to the Print name of Owner Catawba County LHD and the system shall meet applicable federal,State,and local laws, regulatigns�s and ordinances. Glenna• Bir d(Aug 24,2022 09'05 EDTi Aug 24, 2022 Signature of Owner Date This section for OW Use Only. [HD 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). A copy of this complete NOI/ATO with tracking information was sen for the State on 9 1217.1- via Wii i n N�4 f 441— 14,4„. ,/JJ A to Finail,FAX, 1USPS,Hand delivered Print name of authorized Agent of the LHD Signature of 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. DHNS/EHS/OSWPB—LSS COVID-19 COMMON FORM Effective September 8,2020 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 Ccdathi6A LHD Reference Number ?— ID_ital. 154 D32_ Permitting backlog as of date of NOI submittal(#days) '1° doays Number of days to process the NOI(#days) 5 jar Number of days to process re-submitted NOI(#days or „NA,.) _NA (('' Facility type c31Aett '[Qt1'tl II CI war, Domestic,High Strength or IPWW DtWIrshG Design Daily Flow List) Residential or Commercial geSidlekkai System type(per Rule.1961) Date of Post-construction conference cg D 4171 Date Authorization to Operate issued { l - Fee charged for LSS COVID-19 .113 5, Is fee sufficient to cover LHD costs•? ye5 Date LHD notified of LSS COVID-19 malfunction Date LHD notified of Owner complaint DHHS/EHS/OSWP—COVID-19 Appendix A Updated February 2022 Page 4 of 4 Residential Subsurface Wastewater Treatment and Disposal System COVID-19 Proposal for Lot 126 — Millstone 4856 Stone Drive Conover, NC 28613 PIN # 3744-1822-5247 September 29, 2021 Prepared for: Glenn Bird Century Complete 9325 Center Lake Dr., Suite 160 Charlotte, NC 28216 1-833-791-0192 Prepared by: Michael G. Wood, LSS Eo Sclt se4e Thompson Environmental Consulting, Inc. .s„ `G w 0�rs� PO Box 541 )&ePtik9 ► Atfr -, Midland, NC 28107-0541 ..a„!_. Phone: 704-301-4881 1219 larry@thompsonenv.com " "' Lot 126-Millstone Century Complete has contracted with Thompson Environmental Consulting (TEC) to prepare a septic proposal for a new 4-bedroom single family residence to be located on Lot 126, Millstone, 4856 Stone Drive, Conover, North Carolina (Catawba County PIN: 3744- 1822-5247). Based upon a soils investigation performed by TEC, it has been determined that a sufficient amount of"Suitable" Group IV soils is available for the installation of Gravity Horizontal Prefabricated Permeable Block Panel System (H-PPBPS) with a 50% reduction for the initial and repair systems at a 0.30 GPD/ft, sq. long term acceptance rate (LTAR). The property is served by a municipal water supply. The enclosed Licensed Soil Scientist Evaluation is being submitted pursuant to and meets the requirements of SL 2020-97 Section 3.19. Century Complete requests that Catawba County Environmental Health (CCEH) issue the appropriate permits for a subsurface wastewater treatment and disposal system based upon the following proposal and the enclosed LSS COVID-19 permit option. Location From Conover, take 1' Avenue north. Take a left onto County Home Road for 2.2 miles, then a right onto Lee Cline Road for 2.5 miles. Left onto Houston Mill Road for 0.4 miles, left onto Sone Drive. Lot will be on left in approximately 0.3 mile. References Laws and Rules for Sewage Treatment and Disposal Systems, 15A NCAC 18A, Section.1900, Department o f Environment and Natuaral Resources, Division of Environmental Health, On- site Wastewater Section, December 6, 2018. Design, Installation and Maintenance of the T& J Panel Wastewater Treatment System; 2021,published by T&J Panel. Primary Investigator's Credentials NC Licensed Soil Scientist No. 1219 SC Professional Soil Classifier No. 114 2 Lot 126—Millstone Plans and Specifications A. Septic Tank 1. The septic tank shall be State approved (Section .1953 of 15A NCAC 18A), watertight, structurally sound, and 1,000 gallons in capacity. 2. The septic tank will be fitted with an approved effluent filter and riser for easy access and periodic maintenance. 3. It is the responsibility of the septic contractor to thoroughly inspect the septic tank prior to accepting delivery to assure that the tank has had time to properly cure and is free of cracks or other structural deficiencies. B. Pipes and Fittings 1. All discharge piping, connectors and supply lines should be made of SCH 40 PVC. 2. All joints must be properly "welded" utilizing the appropriate PVC cement for each application. 3. The supply line from septic tank to the distribution box (D-Box) shall be 3-inch Schedule 40 PVC (approximate length of supply line is 40 feet). 4. There shall be a threaded PVC union above each pump to facilitate easy removal of the pumps for maintenance or replacement. C. Distribution Method—Distribution Box(D-Box) 1. The drainlines will be fed a distribution box. Distribution box shall be water tested and level at the time of the final inspection. D. Drainfield Installation 1. The drainfield and the proposed septic tank location have been marked on-site utilizing metal stemmed flags. Once this area has been approved by the county, the property owner/builder should mark this area and isolate it as much as possible from construction traffic.Prior to the system installation,the septic contractor shall contact the county for a preconstruction conference at which time the drainfield area will be re-verified. 2. Under no circumstances shall any construction take place within the drainfield area while the soil is in a wet condition. If the installer has doubts as to whether or not the drain field area is dry enough to begin construction, the environmental health specialist for this area should be contacted for permission to proceed with the installation. 3. The specified system is a Type III-B/E/G pump to pressure manifold then gravity flow to prefabricated permeable block panel system — specifically the 16-inch high panel system manufactured by T&J Panel Wastewater Treatment System, Patent No. 4013559; telephone: 1-800-222-2577. The installer must follow the manufacturer's guidelines for installing the T&J Panel System and should request an installation manual from the manufacturer prior to beginning construction. 3 Lot 126—Millstone 4. The initial drain field consists of five (5) lateral trenches 3 feet wide by 40 feet in length. 5. It is essential that the lateral trenches be constructed on contour with the land, with each trench being excavated level from beginning to end.The use of a tripod mounted engineer's level is essential to assure that each trench is constructed as level as possible. 6. The maximum trench depth for this system shall be 15-inches on the Low-Side of the trench. Each trench shall be placed on a minimum of 9-foot on centers. 7. Once trenches are dug, the side walls shall be raked and a light dusting of lime applied. 8. Backfill the trench with 6 inches of sand and level to grade. Once leveled, place 1 x 4-or 6-inch boards on top of the sand the entire length of each trench. Once the grade boards have been set, the panels may be set into the trench. The panels should be placed 6 inches apart. 9. Once the panels have been set, line the top chamber of each panel with 10— 12 pounds of clean particle sand (medium sand blasting sand). Coverage depth should be approximately 1 inch thick. Please note that this sand is not the same material specified for backfill. 10. Tar seal rope, or approved foam, should be placed in the "U"outs of each end of the panel to form seals. Once the tar rope is in place,the 2-inch Schedule 40 PVC laterals can be added and the seal completed by the addition of more tar rope on the top and sides of the pipe. Now that the connection and seals are complete, a block cap is placed on each end of the panel so that all openings are covered. 11. Once the lateral has been installed and the panels closed, the trench is ready to be backfilled to the top with the sand used in the trench bottom. Initial&Repair Systems-Millstone Lot 126 Field Line f Color Initial/Repair Field Length System Length Setup 11 Setup$4 Setup es Relative Elevation 1 Blue Initial 60 50 5.25 100.0 2 Pink Initial 88 88 7.95 3.3 97.3 3 Yellow Initial 90 90 5.85 94.8 4A Blue Initial 43 43 8.6 92.0 48 Blue Repair 43 43 5 Pink Repair 87 87 11.5 89.1 6 Yellow Repair 85 85 14.6 2.3 86.0 T Blue Repair 88 88 5.7 82.6 8 Pink Repair 89 89 9.55 78.8 E. Final Landscaping 1. Final cover over the drainfield shall be at least 6-inches deep. Additional soil cover may be required to achieve the 6-inch requirement. 2. The drainfield will require soil stabilization matting 3. The drainfield shall be shaped to shed rainwater and be free from low spots. 4. The entire area of the drainfield should be planted with grass as soon as possible to prevent erosion. The soil should be properly tilled, limed(if necessary)and fertilized prior to planting. After applying grass seed,the area should be heavily mulched with straw or other suitable material. 4 Lot 126—Millstone F. Utility/Drive Conflicts 1. The builder and property owner must take special care in planning for utilities(water, power, gas, telephone, cable lines, etc.). All utilities shall be kept clear of the septic system and its proposed repair area. Improper planning for underground utilities can negatively impact the installation and, in some cases, cause irreparable damage and permit revocation. If there are any questions regarding preferred routes, contact the County as soon as possible. 2. Water lines must be kept at least ten (10) feet from any portion of the septic system. 3. Irrigation systems should not be placed in the drain field area. Maintenance G. In General The designed system does not require ongoing maintenance via a person certified(Certified Subsurface System Operator)by the North Carolina Department of Environment and Natural Resources to operate subsurface wastewater systems(Section .1961 Maintenance of Sewage Systems). However, the following maintenance should be considered by the owner. 1. The homeowner must maintain the drainfield area through periodic mowing. The drainfield must not be allowed to become overgrown. 2. The septic tank should be pumped every 4 years or when the solids within the septic tank reach an elevation that is equivalent to 25%of the volume of the tank. In some situations, the tanks may need to be pumped more frequently. If you are using a garbage disposal, it is recommended that the septic and pump tanks be cleaned out annually. 3. When it becomes necessary to clean the effluent filters,the filters should be removed, and the accumulated debris washed back into the septic or pump tank— not onto the lawn. 4. Any damp areas, leakages or malfunctions in the drainfield should be addressed immediately. 5. Divert gutter downspouts and surface water runoff away from the drainfield and septic and pump tanks. 5 Lot 126—Millstone Initial System Design Specifics Daily Design Flow: 480 GPD—4 bedroom house Effluent Loading Rate: 0.300 GPD per sq. ft. Drainfield Type: H-PPBPS(50%Reduction) Maximum Trench Depth: 14 Inches Supply Size: 3 Inch Supply Line Length: Approximately 40 feet Number of Drainlines: 6 **Drain Lines: (5)3' Wide x 43-44' Long (1) 3' Wide x 50' Long **Drainline Spacing: 9 Foot on Centers Total Trench Length: 267 Linear Feet Distribution Method: D-box Total Number of Panels: 62 Final Cover Requirement: 6 Inches ** See drainfield layout for site locations and more details. Repair System Design Specifics Effluent Loading Rate: 0.300 GPD per sq. ft. Drainfield Type: PPBPS(50%Reduction) Installation Trench Depth: 16 Inches Required Linear Footage: 266 Feet Available Linear Footage: 392 feet 6 503601\r}{e R5- k); 1-i- I.DANIEL D.EVANS(NCPLS 1-51641,HEREBY CERTIFY THAT THIS MAP WAS DRAWN UNDER MY SUPERVISION FROM AN ACTUAL SURVEY MADE UNDER MY SUPERVISION;THAT THE RATIO OF PRECISION DOES �,,,�,,,1`LCA 111141 i„���'4 �pag, NOT EXCEED AN ERROR OF CLOSURE OF ONE FOOT PER 10.000 FEET ��� i1 O fi 37 StA,yu OF PERIMETER OF THE PARCEL OF LAND(1:10,000):THAT THE `�4�,,.tine/IIQ.�•Kv�S o BOUNDARIES NOT SURVEYED ARE SHOWN AS BROKEN UNES PLOTTED Q,a0 =V . - FROM INFORMATION FOUND IN(REFERENCES AS SHOWN),AND THAT26/ THIS MAP MEETS THE REQUIREMENTS OF THE STANDARDS OF PRACTICE I ,4 SEALC'9 FOR LAND SURVEYING IN NORTH CAROUNA(21 NCAC 56.1600). - L-5184 ? = SITEWITNESS MY ORIGINAL SIGNATURE,LICENSE NUMBER.AND SEAL. PRELIMINARY MAP `%d.t. fifz ,zAtlitio....,..4.- NOT FOR RECORDING, SALES, ,, D, �.0 OR CONVEYANCE 4/26/21 ',,,,,mu,,,,, NOT TO SCALE PROFESSIONAL LAND SURVEYOR DATE VICINITY MAP 4.4 RBF Lot 126 Millstone PB PG62 a PIN 037441022639E ,�qc� i 14856 Stone Drive so5T ' p - _ _ 44 RAF SRF -r - 9C LEGEND c i •=SPOT ELEVATION o=COMPUTED POINT y�Z 1' Q B3 B S h DB=DEED BOOK Q FH-FIRE HYDRANT 3 , FY=FRONT YARD SETBACK �9 PB=PLAT BOOK W �' . - P(} PG=PAGE �� 0 ' RBF=REBAR FOUND it' . RY-REAR YARD SETBACK 6 Oqr2P5 LOT6 PG 136 RW=RIGHT OF WAY • ‘.6 PIN 4374118226221 SRF=SMOOTH ROD FOUND t S yy Ia. Al - 5- t 8 SY=.SIDE SIDE YARD SETBACK , ,..1%P TF=TRANSFORMER T 70 TP= TELEPHONE PEDESTAL I - &� AAIQA WM=WATER METER 0 A ��Jr n WV=WATER VALVE t • A�143 - TQi - - Initial Drain Lines LA� V Center Feed Repair Drain Lines �b 4 L1 50' LOT 125 PB56PG,36 SFP'fj _ cg f Lines 2-4A Q Soil Borings Milc / ' PIN M374417224386 ,t, �t D•0 1C IT It - I 3 S l Q ESSEX B—RH A ( N. \ , LINETYPE LEGEND I 17s \-# =LINES SURVEYED t� 20E • - — — — -=LINES NOT SURVEYED _ _ �- J) Fy ------ =ROAD RIGHT OF WAY 3 • � . ' J f 1 .h. —=SETBACK LINES . •- .• l rI' • 30 � u' , TF 4 .B* , N SOIL$ 0. . if, i vemC pwM r.«..• 9 FH v .+ aIr4 RBFN45°16'29 W 100.00'• wv 100.0 HATCH LEGEND 1ln STONE DRIVE . . qt 47.5'PUBLIC RW , __ _ PB56PG136 4 5KRPE• . PPBPS Design Worksheet PIN: 374418225247 Address: 4856 Stone Drier System Requirements Conover. NC Design Flow 480 GPD Consultant:Michael Wood L TAR 0.3 GPDIft^2 Phone: 919-417-8027 Linear Footage 533 ft.(conventional) Linear Footage 400 ft.(25%accepted) Linear Footage 267 ft. (50%reduction) Initial Design Layout Laterals I ength(ft) #Panels Gal/Line Line#1 50 12 57.7 Line#2A 43 10 49.6 Line#2B 43 10 49.6 Line#3A 44 10 50.8 _ Line#3B 44 10 50.8 Line#4A 43 10 49.6 Totals 267 62 308.1 Thompson Environmental Consulting,Inc. Ares 1 a PO Box 541 PROPERTY in+r. 3-401-1841'S x 9 1- Midland, NC 28107 COUNTY:C 4rA WL A SOIL/SITE EVALUATION Jar ON-SITE WASTEWATER SYSTEM OWNER: KAttt6Atgf i Dimir 414-I510 ADDRESS: DATE EVALUATED:_4,f 2.4 iZ 1 PROPOSED FACILITY:Arli PROPOSED DESIGN FLOW(.1949) PROPERTY SIZE: D .Li . LO CATIONOF SIh 4Q5 '?O& DRIv(, CONOV(R) Ai 2561 PROPERTY RECORDED: WATER SUPPLY: 0 Private Public 0 Well 0 Swing 0 Other EVALUATION METHOD:XAuga Boring 0 Pit ❑Cut TYPE OF WASTEWATER: AScwagc 0 Iadusirial Process 0 Mixed • i P R O SOIL MORPHOLOGY OTHER ✓ (.1941) PROFILE FACTORS 1 ass a LANDSCAPE RORIEON Kamm Danz 1942 PROFILE ✓ SLOPE% M ) .1941 .1941 SOIL .19/3 .1961 _1944 CLASS STRUCTURE/ CONSISTENCE/ %WI NBSB& SOIL. SAPRO RESTR &LTAR TEXTURE MINERALOGY COLOR DEPTH CLASS BOWE p- xa Sak1J f i/hc Ns,►tJP4A/& - Ly 2o- 30 t& ss sPP.E P5 1 3O- ID 1 lai-7c t<� s s r )40 (35 L b O . I 61(J Oa NI! ,IQ/kit g B4. 5+'Jc1 ,5 5S'f r` sE it 2 2.Z 34 * 0/.Plri. izAI N — 3� 3q p, 3 0 -4 �cfo jvrc ifs,Nf1 NJ_ - t f t - 20 SOK1 zf F cs SP \ 110 J J p 3 28 pia i- fir _ o(-1, -- 1id0 D. IS R8) a i•FgSAt 7 p o -le cKIsc/ir ss, SF; 56 5S ,19 - 33 $9 Ste/HI sT, SP g P5 4 / 33i- Al � Ia m� N m6 33 33 - 3 L) f o ' D6sCst 6 TION PIMA"'SYszsa[ REPAIR SYSTEM OTHER FACTORS(.1946): Available s (_I945) es �S SITE CLASSIFICATION(.1948): ?toy, Ju if 470, •i�� d p a .o�w..2 Elam TYPe(s) !!�Ce P � H- Pf 6 I-5 EVALUATED - o oD I f1 '{� . , i. SieeLTAR 0.3 d e 3 `qe ic, COMMENTS: Updaeed Feborry 2014 r— — -- — SOIL/SITE EVALUATION Sheer Gof (Continuation Sheet-Complete all field in full) PROPERTY ID I: 3 P L q -t8 U -Sit( DATE OF EVALUATION: I- -2 I COUNTY: Cft►el keg • a • ■ • • o SOIL MORPHOLOGY OTHER F (1941) PROFILE FACTORS e LANDSCAPE HORIL .1942 POSIT ON/ ON .1941 .1941 SOIL .1943 .1956 .1944 PROFILE M 3LOPEX DEPTH STRUCTURE) CONSISTENCE/ WETNESS/ SOH, SAPRO RFSTR CLASS TEXTURE MINERALOGY COLOR D rig CLASS ASS HORIZ A LIAR 0 / l t,R /sL f V AU, #vV/ Alt 11-36 s8K is /F: SS, S? ,se ! 3t COM MIN IS L'pasted Fcbluuv 2014 August 25, 2022 RE: Septic System Installation Lots 112, 118,and 126—Millstone Subdivision The purpose of this letter is to confirm that the septic system installations for Millstone Subdivision— Lots 112, 118, and 126,Conover, North Carolina was installed in general accordance with the proposal submitted to your office by Larry Thompson, LSS. Sincerely, cr/W/16::tZ. & f4'/4 �)Sidney L Gas,Jr. (Aug 26,2022 05:00 EDT) Sid Gaskins Water Management of North Carolina, LLC 4744 Celia Creek Road Lenoir, NC 28645-6706 Glenn Bird Century Complete 9325 Center Lake Dr.,Suite 160 Charlotte, NC 28216 Subject: Septic System Installation Acceptance Lot 126—Millstone 4856 Stone Drive Conover, NC 28613 The septic system installed on the above referenced property was specified by Larry Thompson, LSS, and installed by Sid Gaskins. I,Glenn Bird,do hereby accept the septic system installed on Lot 126—Millstone. Glenn Bird (signature) Date NOTARY: State of North Carolina } County of ,ilULclanby,r5 } I, DIA1tf1101tr SIE4teiVS , Notary Public, do hereby certify that �enn /6fd personally appeared before me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal this A 5 day of PrIky.S , 20 (Official Seal) / Dominique Stephens Official Signatur otary NOTARY PUBLIC Mecklenburg County.NC Dec^�n% Li--phe11S My Commission Expires Aug ., +g 2 Notary's Prilled or Typed Name Notary Public My Commission Expires: $f i / t" A�Q� DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 8/14(2022 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 pollcy(ies)must have ADDITIONAL INSURED provisions or 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). PRODUCER CONTACT NAME: Betsy Darst RIC,a Bankers Insurance Company PHONE FAX 128 NC-65 (A/L.No.Euty 336-280-0316 _ (A/C,No):800 899-0146 E-MAIL Reidsville NC 27320 ADDRESS: bdarst@bankersinsurance.net INSURER(S)AFFORDING COVERAGE NAIL* License#:8387078 INSURER A:Frankenmuth Mutual Insurance Company 13986 INSURED WATEMAN-01 INSURER B Water Management of North Carolina, LLC 4744 Celia Creek Rd INSURERC: Lenoir NC 28645-6706 INSURER D: _ INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:880362191 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD 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. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXPW LIMITS LTR ,*ISO WVD POLICY NUMBER (MDDIYYYY) (MMIDDIYYYYI A X COMMERCIAL GENERAL LIABILITY 6657470 2/26/2022 2/26/2023 EACH OCCURRENCE S1,000,000 DAMAGE TO ] CLAIMS-MADE I OCCUR PREMISES EaENTED occurrence} $1,000,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEM.AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 X 1 POLICY JEC7 LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY 6657469 2/26/2022 2/26/2023 COMBINED SINGLE OMIT $1,000,000 Jga accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS y HIRED v NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY — AUTOS ONLY (Per accident) A UMBRELLA LIAR _ OCCUR 6657470 2/26/2022 2/26/2023 EACH OCCURRENCE $5,000,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$1n.prv) A WORKERS COMPENSATION 6657468 2/26/2022 2/26/2023 X AND EMPLOYERS'LIABILITY SEATUTE ER ANYPROPRIETORJPARTNER/EXECUTIVE Y� E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? I I N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Leased/Rented Equipment 6657470 2/26/2022 2/26/2023 Max Per Item(ACV) $100,000 Deductible $500 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule.may be attached If more space Is required) The Workers Compensation policy contains an Owner/Member exclusion for Sidney Gaskins. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Thompson Environmental Consulting ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 541 Midland NC 28107 AUTHORIZED REPRESENTATIVE USA bL:t4. . beriglt— ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD