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Home My WebLink AboutLSSP-12-2021-162394.TIF , 1 $6.) Tr;P IeiiS aflv. (za . Nev L �`f ( z- °`r -' 1 3 (y ,`%,,AT ;� r � ' ao ROY COOPER • Governor ii" ` ' 4'y? NC DEPARTMENT OF Ili `=t..¢ MANDY COHEN, MD,MPH • Secretary g/ HUMAN SERVICES MARK T.BENTON • Assistant Secretary for Public Health «� "•' • • Division of Public Health , 4611- _Oc_ Z OL I_ z v'1 S' 7 u(ft, Q ,^ I/00 EHm-07-Do.'-.3 .307awelt COMMON FORM FOR LICENSED SOIL SCIENTIST COVID-19 PERMIT OPTION FOR NON-ENGINEERED SYSTEMS CI ff Ilcatlbi'� See Instructions for Use in Appendix A ` Except for"Date received",this Section to be completed by the!SS 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: IZ-I H.r l___by g I9 Date Initials PART 1:Notice of Intent to Construct(NOI) ll New ❑ Expansion ❑ Repair-LHD Permit Number ❑Repair-EOP/LSS Permit Number 1. Facility Owner's name:(Owner,Company Name,Utility,Partnership,Individual,etc.): Marshall Meyers _ , Mailing address:4454 Hunter Rhyne Rd_City: Lincolnton_State:_NC_Zip: 28092_ Telephone number: _704-701-9180_ E-mail Address: _mallen0121@gmail.com_ 2. Licensed Soil Scientist(LSS)name: Caroline J. Edwards LSS License number:_1220_ Mailing address:_991 Duncan Rd_City:_Rutherfordton State:_NC Zip:_28139 Telephone number: _828-289-0122_ E-mail Address: _cjedwards234@gmail.com 3. Licensed Geologist(LG)(if applicable)name:__NA 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: III LSS ❑ LG 5. Property location(physical address,tax parcel identification number or subdivision lot,block number of the property to be permitted):1862 Tripletts Farm Rd Newton Tract 2 PIN 363813126846_ County Name:Catawba_ 6. Type of facility: II Place of residence No.Bedrooms:_3 No. Occupants:_2_ ❑Place of business Basis for flow calculation: ❑Place of public assembly Basis for flow calculation: NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH LOCATION:5605 Six 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 I AFFIRMATIVE ACTION EMPLOYER State of NC LSS Permit Option COVID-19 LHD Reference:LS.117-1 L`2 OL(-I‘L 5 ci ir 7. Factors that would affect the wastewater load: None 8. k.19b1)ofwa5tr�uaiersy+�tCnr. Type llig Behind and left of residence L . rig om es reet ing e a s y esidence 9. Design wastewaterfifbw: 3 B O gpd Design wastewaterstrength-. ®domestic ❑high strength ❑industrial process(For industrial process wastewater,a Professional Engineer licensed in accordance with G.S 89C shall design the on-site wastewater system.) 10, A plat as defined in G.S.130A-334(7a)is attached: ❑Yes ®No A site plan as defined in G.S.130A-334(13a)is attached: ®Yes ❑No In accordance with G.S.130A-335(f),an LSS COVID-19 Permit with a plat is valid without expiration and an LSS COVID-19 Permit with a site plan is valid for five years. 11. Owner meets requirements of ownership or control of the system per 15A NCAC 18A.1938(j): ®Yes ❑No 12. Easement,right of way or encroachment agreement required per 15A NCAC 18A.1938(j): ❑Yes ®No If yes,documentation filed in County Register of Deeds in Deed book Page 13. Multi-party agreements required,as applicable,pursuant to 15A NCAC 18A.1937(h): ❑Yes ®No If yes,agreements filed in_____ County Register of Deeds in Deed book _Page 14. Location of proposed or existing wells(drinking water,irrigation,geothermal,groundwater monitoring, sampling,etc.)and any potable and non-potable water conveyance lines is indicated on attached plans and complies with 15A NCAC 18A.1950: ®Yes ❑No This is a saprolite system. ❑Yes ®No 15. Evaluation(s)of soil conditions and site features in accordance with G.S.130A-335(a1)signed and sealed by a LSS is attached: ®Yes ❑No 16. Evaluation of geologic and hydrogeologic conditions signed and sealed by a LG is attached ❑Yes ®NA 17. Proposed landscape,site,drainage,or soil modifications are attached: ❑Yes ®NA Attestation by LSS pursuant to S.C.2020-97,Section3.19and G.S.130A-336.2 Ca IU line J. Edwards hereby attest that the information required to be included with Licensed Soil Scientist(Print Nome) this Notice of Intent to Construct is accurate and complete to the best of my knowledge and that the proposed system shall meet applicable federal,State,and local laws,regulations,rules and ordinances,and that the proposed system does not require a Professional Engineer,licensed in accordance with G.S.89C,and in accordance with 15A NCAC 18A.1938 and activities determined to be engineering as determined by the North Carolina Board of Exa iners for Engineers and Surveyors." Caroline J. Edwar s 1 /14/21 - Caroline . �lynamrc t,ci a ,!flat Date DHHS/EH5/OSWPB—LSS COVID-19 COMMON FORM Effective September 8,2020 Page 2 of 6 State of NC LSS Permit Option COVID-19 LHD Reference: ZYJP /2-?dZI `/6 a`s'I Lt NOTES: LIABILITY: The Department,the Department's authorized agents,or local health departments shall have no liability for wastewater systems designed,constructed,and installed pursuant to an LSS COVID-19 Permit Option[S.L.2020- 97,Section 3.19(d)and G.S.130A-336.21 RIGHT OF ENTRY: The submittal of this Notice of Intent to Construct grants right of entry to the Local Health Department and the State to the referenced property. ISSUANCE OF BUILDING PERMIT: Once the LHD deems that the Notice of Intent to Construct is complete via signature in the section below,the owner may apply to the local permitting agency for a permit for electrical, plumbing,heating,air conditioning or other construction,location or relocation activity under any provision of general or special law pursuant to G.S.130A-338. DHHS/EHS/OSWPe—LSS COVID-19 COMMON FORM Effective September 8,2020 Page 3 of 6 State of NC LSS Permit Option COVID-19 LHD Reference: Li) B -(2-20-1-( -/613 64 This section for Local Health Department use only. PART 2: LHD Completeness Review of the Notice of intent to Construct "(c) Completeness Review for Notice of Intent to Construct.—The local health department shall determine whether the notice of intent to construct required pursuant to subsection(b)of this section Is complete within five business days after receiving the notice of intent to construct.A determination of completeness means that the notice of intent to construct includes all of the required components.if the local health department determines that the notice of intent to construct is Incomplete,the local health department shall notify the owner and list the Information needed to complete the notice.The owner may then submit additional information to the local health department to cure the deficiencies in the initial notice.The local health department shall make a final determination as to whether the notice of intent to construct is complete within five business days after the department receives the additional information.If the local health department fails to act within any time period set out in this subsection,the owner may treat the failure to act as a determination of completeness. The owner shall be able to apply for the building permit for the project upon the decision of completeness of the notice of intent by the local health department or if the local health department fails to act within the five business day time period." The review for completeness of this Notice of Intent was conducted in accordance with G.S.130A-336.2(c). This NOI is determined to be: ❑ INCOMPLETE(if box is checked,Information in this section is required.) Based upon review of information submitted in Part 1,the following items are missing: Copies of this form listing missing items were sent to the LSS and the Owner on Date via with directions to re-submit missing items using Page 5 of this form. Email,FAX,LISPS,hand-delivered Print Name of Authorized Agent of the LHD Signature of Authorized Agent of the LHD Dote COMPLETE(If box is checked,Information in this section is required.) Based upon review of information submitted in Part 1 of this form,this NOI is deemed COMPLETE. Copies of this signed form were sent to the LSS and the Owner on (z- o 2(via Date Email,FAX,LISPS,hand-delivered A copy of this NOI and tracking information was sent to the State on via Date Email,FAX,LISPS,hand-delivered Print Name of Authorized Agent of the LHD Signature of Authorized Agent of the LHD Date DHHS/ENS/OSWPB—LSS COVID-19 COMMON FORM Effective September 8,2020 Page 4 of 6 State of NC LSS Permit Option COVID-19 LHD Reference: LSf f" - 12-z 0" I D L 3(-1 L( Re-submittal of NOI with missing items included This Section is for use by owner to submit items noted as missing during LHD Completeness Review above. Resubmittais must be accompanied by a cover letter from the LSS. LHD USE ONLY: This NOI resubmittal received: by Date Initials Item#from initial NOI Resubmittal description Attestation by LSS pursuant to S.L.2020-97,Section 3.19 I, hereby attest that the information required to be included with Licensed Soil Scientist(Print Name) this Notice of Intent to Construct is accurate and complete to the best of my knowledge and that the proposed system shall meet applicable federal,State,and local laws,regulations,rules,and ordinances. Signature of Licensed Soil Scientist Date The section below is for Local Health Department use after submittal of items noted as missing above. LHD Follow-up Completeness Review of Notice of Intent to Construct This follow-up review for completeness of this Notice and Intent was conducted in accordance with G.S.130A- 336.2(c). This NOI Is determined to be: ❑ INCOMPLETE Based upon review of information in the RESUBMITTAL above,this Notice of Intent remains INCOMPETE because the following items from Part 1 of this form remain missing: Copies of this signed form were sent to the LSS and the Owner on via Dote Email,FAX,LISPS,Hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Date El COMPLETE Based upon review of information submitted in the RESUBMITTAL above in addition to Information provided In Part 1 of this form,this NOI is deemed complete. Copies of this signed form were sent to the LSS and the Owner on via Date Email,FAX USPS,Hand-delivered A complete copy of this form with tracking information was sent to the State: via Date Email,FAX,LISPS,hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the!HD Date DHHS/EHS/OSWPB—LSS COVID-19 COMMON FORM Effective September 8,2020 Page 5 of 6 State of NC LSS Permit OptIon COVID-I9 LHD Reference: L -5-I f-12-2-°2I—42- ' f PART'3; Authorization to Operate(ATO) Except for dote recolw4 the Section below b to be completed by the Owehr. LH D USE ONLY, Initial submittal of request for Ala received: 10 AO - 21-- by ie 1° Dote Weeds Date of Post-construction Conference: N A i The following hems are Included In this submittal for en Authorization to Operate under an LSS COVID-19 permit: L Signed and sealed copy of the LSS's report that Includes: a. signed and sealed evaluation of soil conditions and she features Ei Yes d No b. Drawings,specifications,plans Yes No c. Reports on special inspections end final inspection 0 Yes No d. Management Program manual 0 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 0 Yes No 1 4. On-site Wastewater Contractor name; l I1 9A-. license number: 1( �4—� mailing address:'L9 jj'L 6-1 { City:\-i-t `SState: V ,, ZIp;, g10.7 7 Telephone number:7t7 9i3 • 2' E-mall Address: $a 15uJ@��an45ept1�4 idlegaiall41 5. Proof of Errors and Omissions or other appropriate liability insurance for the On-site Wastewater Contractor is aa�ttayyhhed and includes the name of the Insurer,name of the Insured,and the effective dates of coverage. [+ "Yes 0 No Attestation by thej Ownery for Authorization to Operate I, AR 3 h4 ii /r1t�e' hereby attest that all items Indicated above have been proviced to the f a�t►omeat°wrier Cici.Yekw Pc4— County LHD and the system shall meet applicable federal,State,and Local laws, regulations,rules and ordinances. / -- — 10 a. sic/natanr a!Owner Date Ibis section far NO Use Only, LND Review of required information for the ATO D INCOMPLETE eased 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 LS5 and the owner on via Date Entail FAX,USAF,Nonddeawtred Prfnt name of authorized Agent of the LHD Signature al authorized Agent of the thy Dote iIKCOMPLETE 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.13DA-336.2{m), A copy of this complete NOI/ATo with tracking Information was sent to the State on A412 via CO 1 L r?.L;,; '�,,; (y I Li , u;;Nona- .d � � C di 1 - PriM name 400104,d Apt*of the zHg Signature of authoriced Agentof the tHD bate tssUANCr OF CERrtFiGtrE OF OCCUPANCY:Once the WD detarmtnas completeness based upon the ATO submission,the owner may sooty lathe iceel permitting agency for parmenent etaetriCel seMOa to■madence,place of business or place of public assembly pursuant to GS,13Q4339. OHHSffNSIOS WPa-US COVIO-19 COMMON'FORM Effective September 8,202a Page 6 of 6 LSS COVID-19 Permit Option Tracking information The LHD completes this form for each N01/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 CO-WIWI LHD Reference Number 1-55Q- 1)-)0)1- 1 673g11 Permitting backlog as of date of NOI submittal(#days) 30 days Number of days to process the NOI(#days) y a a/s Number of days to process re-submitted NOI(#days or of "NA") N i Pt Facility type 3 Bedroom +lt&st Domestic,High Strength or IPWW Dories-tic, Design Daily Flow 3i.20 Residential or Commercial PSIdenf Q System type(per Rule.1961) ]335 Date of Post-construction conference Writ,Vea Date Authorization to Operate issued I i l Z2 Fee charged for LSS COVID-19 1 1 o Do Is fee sufficient to cover LHD costs? 1-Pc Date LHD notified of LSS COVID-19 malfunction Date LHD notified of Owner complaint 1 DHHS/EHS/OSWP-COVID-19 Appendix A Updated February 2022 Page 4 of 4 To: C,ctr bet, County Department of Public Health Re: Signed Statement of Verification of nstalled Septic Syst m Address: / '12 a1 �'r l o1�' � rr r+, d, iA'forAd A/L. S;; 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 below. Owner Signature: ,' i , �'`'— Date /U/�/.,7,3\ North Carolina .1-feiz4(( County I, eUJi t P e/C a Notary Public for .Wide 0County, North Carolina, do Hereby certify that fi41a.lrsl%G,t1 �'►'lr try personally appeared before `f me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal, this the day of Debbie Kelly otary put JiC NOTARY PUBLIC - Iredell County y commission expires: 72-i/2-, North Carolina My Comma;:i.•n r,)ires 06.;21/2025 To: Catawba County Department of Public Health Re: Signed Statement of Verification of Installed Septic System Job site: 1862 Tripletts Farm Rd Newton NC My signature below hereby attests that the installation went in as shown on the 'as- installed' Site Plan 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: Rob:tRF(OSt7,202206 49WUI) Date Oct 7, 2022 A R CERTIFICATE OF LIABILITY INSURANCE DATEI0 5i2 22 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 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 CON)AGI NAME: Tyler Windham Farley In Insurance PHNE O --- 20426) Main Si ADDRESS: IA ANo.Ext): (704)274-2033 (4/C, ot:NA tyler(,thefarlcya¢ency.com INSURER(S)AFFORDING COVERAGE NAIC 0 Cornelius NC 28031 INSURER A: ERIE INS CO 2626_ INSURED INSURER B: ERIE INS EXCH 26271 RAY'S WELL AND SEPTIC INSURER C: TECHNOLOGY INS CO INC 42376 ROBERT A RAY JR D.B.A INSURER D: PO BOX 53 INSURER E: HIGH SHOALS NC 28077-0053 INSURER F COVERAGES CERTIFICATE NUMBER: 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. ' 'R AVU ueiN - FOUL?EFF POLICY EXP LTR TYPE OF INSURANCE INSD,(WVD POLICY NUMBER (MM(DD/YYYY) (MMIDD/YYYY) LIMITS A 1 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 15 1.000.000 1 CLAIMS-MADE XI OCCUR J PREMISES/Ea cccrrence) I S 1.000A0U MEG EXP(Any one person) �-5 — 111.000 A Y Y Q61-0082206 03/20/2022 03/20'2023 PERSONAL 8 ADV INJURY 15 1.000,000 I GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I S 2,000.000 POLICY I Km, LOC PRODUCTS-COMP/OP AGG S 2.000.000 OTHER S AUTOMOBILE LIABILITY COMBINEDe,,9NC,(FI.IMII 5 ANY AUTO (EaacadenO 1.000.000 BODILY INJURY(Per person) 5 B OWNED y SCHEDULED AUTOS ONLY A AUTOS Y Y QI0-3040066 10/30,202I 10/30/2072 BODILY INJURY(Per accident) 5 v HIRED NON-OWNED X. AUTOS ONLY A AUTOS ONLY I (Per a c deM)LANIAbe S " i S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR ICLAIMS-MADE '— AGGREGATE S TOED I RETENTION S 'WORKERS COMPENSATION r-- _I IS y STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE I ( C OFFICER/MEMBER EXCLUDED' Y! N fA TWC4O9I7O5 03/20(2022 03,20)2023 E L EACH ACCIDENT 5 I.000.000 (Mandatory In NH) - I res descnbe under I I E.L.DISEASE-EA EMPLOYEES I.000.000 DESCRIPTION OF OPERATIONS bebw ---iii I E.E DISEASE-POLICY LIMIT I5 1.000.000 f _ DESCRIPTION OF OPERATIONS(LOCATIONS/VEHICLES IACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ( r . -- \/\s,A-ek,\tkok cv7 Teimc9 , __allktv.k9A/ ..,.., • t‘m.Q.,,Nt V NJ t i,1 kik. oke.ciV2 i tkl ? (c4L '_ `;>,, > y ''�� , O �Seriul Db-n-z. , > f 0, 4 - , ft , / "Y ,,R 0 r, 1 /2g1 - N / i Home r�' , Q �� D \.,. � r \Tr)r S. '11 36 i ,L....., \ :„....„.„. \ . ,_....„.„ N., `,''g7' TV 1 I I U 4u N [ ,,-, I r mat oi c` $' Soils&Land Evaluation t' c y Site Plan for Marshall Meyers A . --------- - i a- 1862 Triplets Farm Rd Tract 2 Catawba County,NC f"1 00 5— 0October and December,2021 fl� �"' o See attached documents for details. nI 't�''f ` I 10 V ?: i . 7 3so)Rte , fr _ r f 1 , 1 e� .Earthwise Designs as-.)-4,9 Soils& Land Evaluation 10/10/22 Environmental Health Supervisor Catawba County Department of Public Health Re: Verification and Request for No On-site Post-Construction Meeting 1862 Tripletts Farm Rd Newton NC Re:LSSP-12-2021-162394 This letter is to certify that the system at the above referenced address was installed consistent with the Soils and Site Report provided to you. We request to not have the On-site Post-Construction Meeting. All required documents have been provided to your office,including the As-Built Site Plan. Please contact me if you have any questions;thank you very much. Sincerely yours, CV\,, t\z. 414:Caiblme J, warms „a NC Licensed Soil Scientist#1220P1 SC Professional Soil Classifier#117 %%am, NC Land.4pplication of Bic-Solids#10006173 ACRLJ O CERTIFICATE OF LIABILITY INSURANCE f DATE(MM/DD(YYYY) kir— 03/06/2021 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 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: Hiscox Inc. 520 Madison Avenue /C'o•Eon: 202-3007 FI .No): E-MAIL 32nd Floor ADDRESS contacahiscox.com New York,NY 10022 -- - --JNSURERIS)AFFORDING.COVERAGE_. . 'Asir Al INSURER A: Hiscox Insurarce Company Inc 10200 _-_ INSURED Earthwise Designs INSURER a: 991 Duncan Rd INS uRERL_ Rutherfordton NC 28139 INSURER D• — INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER' 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. WSR TYPE OF INSURANCP ADD.9UBR Pnl ICY NIIMRFR POLIC�YryEFF POLICY EXP UMITS -ua-1 tfr I--ir+nvr�a�q- IMMERCiAL GENERAL UABILITY I EACH OCCURRENCE..___- $ _ _...._—. j_ CLAIMS MADE OCCUR DAM�ic� RENTED I -RRF Fa-cccuaancal-._ .$-. .. — i- _-__ ___._ MED EXP-IAoy one.person)_._.,.i_ ----- i 3ERSONALBADVINJURY .1. . GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE . $ POLICY PRO-L�JECT LOC .P_RDOUCTS-rOMp/DB9D.G. $_ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ --- _(Eaacoident)—ANY AUTO BODILY INJURY(Per person) $ _ _____ OWNED I SCHEDULED BODILY INJURY Per accldent $ AUTOS ONLY __ AUTOS ------- — - )— - HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY 1 •IPera -ccident) --.- - . _._..--_._.__.___.- $ UMBRELLA LIAB 7OCCUR i- EACHDCCURRENCE______.$ f EXCESS LIAB CLAIMS-MADE. AGGREGATE $ ___, nFn L LRFTFNTinN$ , ___,_-� _,___ _ - c WORKERS COMPENSATION 1 PER I OTH- AND EMPLOYCR3'LIABILITY Y/N I STATUTE J I ER ANYPROPRIETORLPARTNER/EXECUTIVE I I N 1 A E.L.EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED? __- (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under -- —_ DESCRIPTION OF OPERATIONS below _ - E.L.DISEASE-POLICY LIMIT $ A Professional Liability Y UDC-1571046-EO-21 04/20/2021 04/20/2022 Each Claim: $2,000,000 Aggregate: $2,000,000 i DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more spate Is required) — CANCEL',ATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD I • Earthwise Designs Soils&Land Evaluation 12/8/2021 Site and Soils Report with System Design Three-Bedroom SFH Wastewater System 1862 Tripletts Farm Rd. Tract 2 15.554 Acres PIN: 363813126846 Catawba Co. NC Prepared for: Marshall Meyers This report is submitted under the rule: LSS COVID-19 PERMIT pursuant to S.L.2020-97,Section 3.19 and G.S. 130A-336.2 PART 1: Submittal of Notice of Intent to Construct(NOT) Earthwise Designs has performed a soils and site evaluation of the lot referenced above. We have found an area Provisionally Suitable for the following initial system: 3-bedroom IIl g. gravelless trench with 25%reduction. This is not saprolite system. A new well will be dug. Details are discussed below and in attached documents. System Specifications Initial & Repair:III g. gravelless trench,Approved Accepted system with 25%reduction. Gravity fed. See site plan. • Soils: Group IV—Clay • LTAR: 0.3 (See detailed soil descriptions.) • Line length required=300' o Three 100' lines. • Trench width 36". • Trench bottom: 26"on downhill side of trench. • Septic tank: 1000 gallons Other site-specific requirements and notes: I. No cut or fill can encroach on the drainfield area. 2. No structures or roads can be placed in initial or repair area. 3. Heavy machinery over the drainfield area must be avoided after installation. 4. The owner must ensure that the field is installed as described above; will be maintained to reduce erosion,shed water,retain a vegetative cover and not be disturbed. /7,5 /p i- 2 5. Earthwise Designs makes no guarantees regarding installation,maintenance and operations. System design may not be accurate if improper site alterations occur prior to permitting and installation. Thank you and please contact me for further information,if needed. Caroline J. Edwards NC Licensed Soil Scientist#1220 ��`°sou SofF� SC Professional Soil Classifier#117 .Gr°, , �s� NC Land Application of Bio-Solids #10006173 Y7 �, Attachments: % 1220 Site Plan,three pages `t`aR+ Soils sheet,two pages Plat GIS Aerial PS 2 .f" EARTHWISE DESIGNS 991 Duncan Rd Rutherfordton,NC 28139 Ciedwards234(@.amail.com 828)289-0122 cell Ct r� Earthwise Designs 1862 Tripletts Farm Rd. Tract 2 Soils&Land Evaluation Catawba Co.NC PIN: 363813126846 15.554 Acres October and December,2021 Legend and Notes for Site Plan See written report for additional details. • III g.gravelless trench with 25%reduction. o Infiltrator product recommended. • Soils Group IV. LTAR:0.3 • Three 100' lines,connected with endcaps and pve pipe. • Lines shot on 9' centers as indicated. O=orange metal stakes;B=blue;Y=yellow;P=pink. • R=repair lines below shop. • Circled dots 1-5=pit numbers and locations. • Well site marked with wooden stake and blue flagging. Additional locations from fixed points: PC1 point on property line marked by surveyors rebar and pipe.(See southeast corner of site plan.) Pecan=3'isolated pecan tree. Pit 1:290' from PCI;35'from Pecan. Pit 2:324' from PC I;89' from Pecan. Pit 3:366'from PC1; 132' from Pecan. Pit 4: 152'from PC1; 160' from Pecan. Pit 5:78' from PC1; 190'from Pecan. ,,p SOU.sci, k (?'0 )4"... '""'"' "" SS,.....12213 6 3 ,f 9 /0 • e k\N ‘, tk i -Q Ci \? 41 ? \ c wai.c.ryt ,., "hi (Serial,0,01 4,Tioh 4Cj: i ze co,s -y_ T a iu 1261 ?6 s ' \ (e/f Trf -,-•3it-+'Pe cash li-e+ 3 ' It rp! 1 , ' I 9.oI - �,, ig :: s Earthwise Designs <: , ' Soils&Land Evaluation ti ccli Site PIan for Marshall Meyers - i a. 1862 Tripletts Farm Rd Tract 2 f,10 . Catawba County,NC a October and December,2021 L See attached documents for details. l 00 r6 lad` - t AI r._ ------•-,),... 0 •14,KeNts? `.-", p.ram ,Z.'� r t'''c G� Q't C.1. C+114,- a-17-9it Pa #--er^q Aiir 1 i n . � Earthwise Designs '��'S, d '^'` sods&Land Evaluation Site Plan for Marshall Meyers top 60e.sir, 1862 Tripletts Farm Rd Tract 2 l• k \( \M t k ,`kkG'E•'ci: '� Catawba County NC t ;+ - �� ; •` October and December,2021 �, C —'d`""`` See attached documents for details. C a' (. -- "w i • £6NfFlOL N e7'35'36"E 714.45' CORNER 11 t �� Vi j Q, 1/ 'BRACT 2 '\ I. I \l 15,554 ACRES 1 Gina Jo Ok iuccio \t 2561/1S58 , 4 ` a SEE 1NSEC A' * 45' RocOf-WAY n SEE DEED OF EASEMENT AND • CORNERl .0.1?$AG. Ct,lt ROAD►aIN EIANCE AGREEMENT we Wu ii — w tA4.si' V t{�- 2170f1475 I N 89'21124"E 5 02°19'16T i 1 -�wT f -"1 172.79' 45.02` • E\\\,>_ ,....... .,......,: ;7:Z:7Z:.r..:1 TIZ.Illih- 1 61.0•3' \\.............-....-....- TIE MY TRIPLE S FARM tf 1aw . _ ,/ff El . _ tOs.77' �z1 3 R nsNce I ROAD r, vi-fauc a Hs e SQ'RA/AS SHOWN ON UNRECORDED xA>L I .11 PLAT VANE MILLS PROPERTY" ow- miNa steE of NAAR S O2°47'54"W 1b' cp. 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I [----- 1.1 il 1 ik' 1 111 II hì ' � li p 1111! • ti # r--1= gassy v� / \ - r-ja_ ; :a : �` I igj:rill .1 i� Z ii}#4' ins •._ E i • ',I. .- po. }�a 6 oilill I jr 1 ! 414_,, i ! ti \\ li h iø1J4is !I AAA 1 I • ;' catawba county Geospatiai Real Estate Search MAKING.WONG.HMI. information Services s rC�R: t'�1:a Y+ .1111K ..- .. 'SR �r - ! 7 i'r.•• — - > - , . - r r 4•.`"• w rr aul, i Ap fr,• a• ' ' y•Yi% S, T'a j R J• , k' ,' • r� l�._14 S At'-4. , 1 Ir . ,..„:,..:. .„,„.•,:,... . : foit i ,.. . , .. ., , ,r—, ,.k. • x.. J - y��R_ 7s lin=300ft W+E s Parcel: 363813126846, 1862 TRIPLETTS FARM RD NEWTON, 28658 Owners: TRIPLETT FARM TRUST, Owner Address: 4454 HUNTER RHYNE RD Values - Building(s): $3,200, Land: $69,300, Total: $72,500 6 o I This map/report product was prepared from the Catawba County,NC Geospatial Information Services. Catawba County has made substantial efforts to ensure the accuracy of location and labeling information contained on this map or data on this report.Catawba County promotes and recommends the independent verification deny data contained on this map/report product by the user.The County of Catawba,Its employees,agents,end personnel,disclaim,and shall not be held liable for any and all damages,loss or liability,whether direct,Indirect or consequential which arises or may arise from this map/report product or the uRe thereof by any person or entity. Copyright 2021 Catawba County NC 09/17/2021 t'(I)