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Home My WebLink AboutLSSP-10-2021-159927.TIFr State of NC LSS Permit Option COVID-19 LHD Reference: LSSP-10-2021-159927 PART 3: Authorization to Operate(ATO) i Except for date received,the Section below Ls t 7 be completed by the Own{. LHD USE ONLY: Initial submittal of request for ATO received: D 517.V by 1•� it Initials Date of Post-construction Conference: Xl5 2,2 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 0 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 es ❑ No 2. Fee(as applicable) Yes No 3. Notarized letter documenting Owner's acceptance of the system from the L55 Yes ❑❑ No 4. 4. On-site Wastewater Contractor name: Butler Bros Backhoe Service License number: 6300 Mailing address:3964 Old NC 18 City: Morganton State:NC Zip: 28655 Telephone number:828)439-3101 E-mail Address: Not available 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. XYes ❑ No Attegetion by the qer for Authorization to Operate ANN � ��` I, lr! A. lflf��..� herebyattest/that all items indicated above have been rove ed to the Print name of Owner �c tizi , Lt1 County LHD and the system shall meet applicable federal,State,and local laws, regula on es and rdina ces. Yeses a 3T '-5 zo Z2na re o Owner Date This section for LHD Use Only. LND 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,LISPS,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 i formation wa sent t the State on S '[}via W 1 U . r Date Email,FAX,LISPS,Hon delivered Re ,111\14(jed b -- Print na of authorized Agent of the 1 HD Sig • of authorized Agent of the 1HD 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. OHHS/EHS/OS WPB—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 Catawba LHD Reference Number (s5 e-Jo-2021- 159137 Permitting backlog as of date of NOI submittal(#days) 30 Number of days to process the NOI(#days) I Number of days to process re-submitted NOI(#days or "NA") n Facility type 3 BDQI, ►` I✓ Domestic,High Strength or IPWW Domesfie Design Daily Flow 31,0 girl Residential or Commercial Ike Sj a iadi System type(per Rule.1961) U' Date of Post-construction conference 5 I22. Date Authorization to Operate issued it in Iz2- Fee charged for LSS COVID-19 les $ 10.C Is fee sufficient to cover LHD costs? .e5 Date LHD notified of LSS COVID-19 malfunction !! Date LHD notified of Owner complaint OHHS/ENS/05WP—COVID-19 Appendix A Updated February 2022 Page 4 of 4 4\ALIAlok,- \LQfkai7eNcth4 . qc)-4— 0 .qc409A0 _- Earthwise Designs 1649 Berlishil.e Dr. Lot 27 0.41 ac. Soils&Land Evaluation Catawba Co. NC September, 2021 See written report for additional details. • Initial system: ITT g_ gravelless trench with 25%reduction. • LIAR: 0.3 • Line length required: 300'. • Serial distribution with 3" pvc • Layout shot on 9' centers as indicated. o Y=yellow flagging stakes;B=blue; W= white. • Circled dots numbered 1-3 =pits. • Buried drainage pipe is sidehill or slightly uphill from drainfield= 15' setback. • House corners marked with wooden stakes and twine. Additional locations from fixed points: PC1-PC2=property corners marked with rebar. Pit 1: 84' from PC1; 35'from PC2 Pit 2:48' from PC1; 92' from PC2 Pit 3: 116' from PC1; 151' from PC2 Fa �stpSQRsofr • I O t . �7""�. 4•. �G Yd- �o�_��rp� I. PGA o,/'",�, -Mbar 9' 'a. � / L t7 ��- if" z e. If' `1/4" lti� f �F '' 1 / k ` t `J r f. AP / s.. 7% - 1rDG„d -4 ,55 I l` j- H @J S f (rift ''e - i e3 j V ee Tie { °J 't91 v '' ei q •• s I . To: Catawba County Department of Public Health Re: Signed Statement of Verification of Installed Septic System at Address: 1649 Berkshire Dr. Hickory 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 present notarized be w. Owner Signature: ,►� Date 20 �� 1 4 nAgml :7P4,1 0 ( p11,01‘, North Carolina Mired c( County I, 1F,,:s Pi0r3an a Notary Public forAl-ianf(r County, North Carolina, do Hereby certify that Ro,,.,.e_/{l)rn -Soi j personally appeared before me this day and acknowledged the due Vexecution of the foregoing instrument. Witness my hand and official seal, this the (Lkl N day of l a.5 , 2022. TRAVIS MORGAN Notary public: i � NOTARY PUBLIC ALEXANDER COUNTY,NC A"- My commission expires: 0 9 - 05 Installer Name Butler Bros. Backhoe Service c/a Leonard Butler Lic. 6300 Address:_3964 Old NC HWY 18 in Morganton, North Carolina 28655 (828) 439-3101 To: Catawba County Department of Public Health Re: Signed Statement of Verification of Installed Septic System 1649 Berkshire Drive Hickory NC My signature below hereby attests that the installation is installed as designed with any as-builts/changes as attached; and 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, rules and ordinances. Installer Signature: , ,,y Y,fte Date— 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(ies) 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 LEONARD BUTLER CERTIFICATE RON JOYCE NAME AND GARLAND BUTLER HOLDER PO BOX 716 ADDRESS 3964 OLD NC 18 HICKORY NC 28603 MORGANTON NORTH CAROLINA 28655 COVERAGES 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. X TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS INSD WVD (MM/DD/YYYY)(MMlDDlYYYY) Ixl COMMERCIAL GENERAL To be assigned 08/10/2022 08/10/2023 GENERAL AGGREGATE $2,000,000 LIABILITY -OCCURRENCE PRODUCTS - COMP/OPS $2,000,000 AGGREGATE PERSONAL &ADV INJURY $1,000,000 GENT.AGGREGATE APPLIES PER EACH OCCURRENCE $1,000,000 POLICY DAMAGE TO RENTED $100,000 PREMISES (Ea Occurrence) MED EXP (Any one person) $5,000 EACH OCCURRENCE u BUSINESSOWNERS AGGREGATE AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT n SCHEDULE AUTOS (Each accident) I I HIRED AUTOS BODILY INJURY (Per person) o NON-OWNED AUTOS BODILY INJURY (Per accident) u GARAGE LIABILITY PROPERTY DAMAGE o __ (Other) (Per accident) EXCESS LIABILITY - EACH OCCURRENCE OCCURRENCE /AGGREGATE WORKERS WC STATUTORY LIMITS COMPENSATION AND N/A u EMPLOYERS' LIABILITY E.L. EACH ACCIDENT POLICY APPLIES TO THE WORKERS E.L. DISEASE - EA EMPLOYEE COMPENSATION LAW IN THE STATE E.L. DISEASE POLICY LIMIT OF NC > OTHER: DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES: CANCELLATION AUTHORIZED REPRESENTATIVE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. DATE 01.7�}o1g efitksa/giv,) COI 0910