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catawba county
public health
VOLUNTARY RELINQUISHMENT OF ADMINISTRATIVE APPEAL RIGHTS
Date prepared: 9/21/2023
Owner(s): Shelley Simon
Mailing Address: 23338 Grayshire Lane
Lake Barrington IL 60010
Property location/site legal description: 1236 Astoria Parkway Catawba NC 28609
PIN: 471001259586
Improvement Permit(IP) IMPV-05-2022-170530 Date Issued 5/2/2022
Authorization to Construct(AC) AUTH-05-2022-170526 Date Issued 5/2/2022
1, SA elle,r �MO/ ,voluntarily relinquish my rights to pursue a formal appeal through the North
(print 1111 name)
Carolina Office of Administrative Hearings pursuant to NC General Statute 130A-24 and I 50B-23 and all other applicable
provisions of Chapter 150B for the above referenced permit(s)(which includes the IPs and ACs)in order for the authorized
agent/local health department to issue the applicable permit(new IP and/or AC)for the site. I understand by completing this form
that the permit(s)for a
25%reduction IIIG
(System description)
will be revoked immediately by the authorized agent/local health department.
I understand that the local health department's revocation of a permit can be appealed to the North Carolina Office of Administrative
Hearings within 30 days of the revocation pursuant to the North Carolina Administrative Procedure Act. I understand that in order for
the local health department to issue another IP and AC that the current IP and AC must be revoked. I understand that the local health
department's revocation of an IP or CA is not effective until 30 days from the revocation or, if the revocation is appealed,at the time
that the Office of Administrative Hearings issues a final decision. I understand that by signing this form and relinquishing my right to
appeal the permit revocation at the Office of Administrative Hearings that the local health department's permit revocation will become
effective immediately. I understand and agree that the revocation of a permit that takes effect immediately is in my best interest. 1
understand that by signing this form that I agree that I do not want to appeal the permit revocation.
I understand that I am not required to relinquish my appeal rights but that this is an option available to me so I do not have to wait 30
days for the revocation of the permit to take effect.
Signature of Property Owner:
Date Signed: 9/a', a3
NCDHHS/DPH/EHS/OSWP Revised May 2015
catawbacountync.gov
Environmental Health
Cc'awba County Government Center
25 Government Drive I PO Box 389 I Newton NC 28658 1828.465.8270
MAKING. LIVING. BETTER.
catawba county
public health
September 21, 2023
Shelley Simon
23338 Grayshire Lane
Lake Barrington IL 60010
Subject: Notice of Intent to REVOKE the Improvement Permit and Authorization to
Construct for 1236 Astoria Parkway Catawba NC 28609 PIN 471001259586
Catawba County Permits IMPV-05-2022-170526 and AUTH-05-2022-170530
Dear Ms. Simon:
The Environmental Health Division of Catawba County Public Health intends to revoke your
Improvement Permit and Authorization to Construct 30 days from the date of this notice.
If the permits are revoked, you must apply for a new Improvement Permit and Authorization to
Construct (IP/AC) and meet the requirements of the current laws and rules necessary to obtain a
new IP/AC.
You have a right to an informal review of this decision. You may request an informal review by
the environmental health supervisor at the local health department. You may also request an
informal review by the NC Department of Health and Human Services Regional Soil Scientist. A
request for informal review must be made in writing to the local health department.
You also have a right to a formal appeal of this decision. To pursue a formal appeal, you must
file a petition for a contested case hearing with the Office of Administrative Hearings, 6714 Mail
Service Center, Raleigh, NC 27699-6714. You may write the Office of Administrative Hearings,
call the office at(919) 431-3000 or get a copy of the petition form from the OAH web site at
http://www.ncoah.com/forms.html . The petition for a contested case hearing must be filed in
accordance with the provision of North Carolina General Statutes 130A-24 and 150B-23 and all
other applicable provisions of Chapter 150B. North Carolina General Statute 130A-335 (g)
provides that your hearing would be held in the county where your property is located.
catawbacountync.gov
Environmental Health
Catawba County Government Center
25 Government Drive I PO Box 389 I Newton NC 28658 1828.465.8270
MAKING. LIVING. BETTER.
If you wish to pursue a formal appeal, you must file the petition form with the Office of
Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. The date
of this letter is 9/21/2023. Meeting the 30-day deadline is critical to your formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative Hearings, you
are required by law(NC General Statute 150B-23) to serve a copy of your petition on the Office
of General Counsel,NC Department of Health and Human Services, 2001 Mail Service Center,
Raleigh, NC 27699-2001.
Respectful
ason Boyd, R S
Environmental Health Specialist
Catawba County Public Health