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HomeMy WebLinkAboutLSSP-06-2021-152371.tif . , q 21 Shec i'�k5 fd M- TE LSSP -04 -.)col-�- �--71 ,ci IA 1 RPk-tio-- 01-3771S r r ROY COOPER • Governor er.5,, 's NC DEPARTMENT OF &,! i( HEALTH AND MANDY COHEN, MD, MPH • Secretary '' - r�y HUMAN SERVICES $,�r" 4; 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: b LI l ( by 1h/7 Date Initials PART 1:Notice of Intent to Construct(NOI) New ❑ Expansion Repair—LHD Permit Number ❑Repair—EOP/LSS Permit Number 1. Facility Owner's name: (Owner,Company Name, Utility, Partnership, Individual,etc.): Scott Marks Mailing address: 129 Live Oak Ln City: Mooresville State: NC Zip: 28115 Telephone number: (704)622-9256 E-mail Address: scott@synlawncarolina.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: cledwards234Pgmail.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: II LSS ❑ LG 5. Property location(physical address,tax parcel identification number or subdivision lot,block number of the property to be permitted):_Lot 1 5863 Sherriils Ford Rd NC 6. County Name: Catawba 7. Type of facility: M Place of residence No. Bedrooms: 3 No.Occupants: 4 n Place of business Basis for flow calculation: I I 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/AFFIRMATIVE ACTION EMPLOYER State of NC LSS Permit Option COVID-19 LHD Reference: ASS' P. V U I ) )3 7 1 8. Factors that would affect the wastewater load: None 9. Type,location,and classification (per Rule.1961)of wastewater system: Type Illg; NE side of house looking from street Single family residence 10. Design wastewater flow: 360 god Design wastewater strength: III domestic ❑high strength ❑industrial process(For high strength and industrial process wastewater,a Professional Engineer licensed in accordance with G.S.89C shall design the on-site wastewater system.) 11. A plat as defined in G.S. 130A-334(7a)is attached: ❑Yes � [I] No 12. A site plan as defined in G.S. 130A-334(13a)is attached: Llil Yes ❑ No In accordance with G.S. 130A-335(fa, 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. 13. Owner meets requirements of ownership or control of the system per 15A NCAC 18A.19380): Yes® No❑ 14. Easement,right of way or encroachment agreement required per 15A NCAC 18A.19380): Yes❑ No If yes,documentation filed In County Register of Deeds in Deed book Page 15. Multi-party agreements required,as applicable,pursuant to 15A NCAC 18A.1937(h): ❑Yes ❑x No If yes,agreements filed in County Register of Deeds in Deed book Page 16. 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: X❑Yes ❑ No This is a saprollte system. ❑Yes ® No 17. Evaluation(s)of soil conditions and site features in accordance with G.S. 130A-335(a1)signed and sealed by a LSS is attached: x❑Yes ❑No 18. Evaluation of geologic and hydrogeologic conditions signed and sealed by a LG is attached ❑Yes © NA 19. Proposed landscape,site,drainage,or soil modifications are attached: 111 Yes • NA Attestation by LSS pursuant to S.L.2020-3,Section 4.18 and G.S. 130A-336.2 Caroline J. Edwards 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, and that the proposed system does not require a Professional Engineer,licensed in accordance with G.S.89C,and in accordance with 1SA NCAC 18A.1938 and activities determined to be engineering as determined by the North Carolina Board of Examiners for Engineers and Surveyors." Signature of Licensed Soil Scientist Date NOTES: DHHS/EHS/OSWPB—L5S COVID-19 COMMON FORM Effective Moy 5,2020 Poge 2 of 6 • 1 State of NC LSS Permit Option COVID-19 LHD Reference: 1--SS P- D , I >):J 7 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.20203, Section 4.18(d)and G.S. 130A-336.2] 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/OSWPB—LSS COV!O-19 COMMON FORM Effective May 5,2020 Page 3 of 6 State of NC LSS Permit Option COViD 19 LHD Reference: L.-J>la 'IA—202_1 -1 5)1 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 Nome of Authorized Agent of the LHD Signature of Authorized Agent of the LHD Date [Er—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 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,USPS,hand-delivered s�br;� phi p,r 1/ - 6-1(-) - ( Print Nome of Authorized Agent of the LHD Signature of Authorized Agent of the LHD Date DHNS/EHS/OSWPB—LSS COVID-19 COMMON FORM Effective May 5,2020 Page 4 of 6 COVID-19 Permit Option Common Form LHD Reference: LSS! O6-2021 - 152371 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. Resubmittals must be accompanied by a cover letter from the LSS. LHD USE ONLY: This NOI resubmittal received: by Date Initials Item II 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 submitted 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 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 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 Dote Email,FAX,USPS,Hand-delivered A complete copy of this form with tracking information was sent to the State: via Date Email,FAX,USPS,hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Date DHHS/EHS/OSWP—L55 C-19 COMMON FORM Updated April2022 Page 5 of 6 State of NC LSS Permit Option COVID-19 LHD Reference: LP O b- 2(-)z H - I CZ- 3 7/ PART 3: Authorization to Operate(ATO) ic..4 \ 5 , 1 51-.111.)<,1,Q pS C-61,,t 0?V Except for date received,the Section below is to b completed by the Owner. LHD USE ONLY: Initial submittal of request for ATO received: '''L(�ZZ by p Initials Date of Post-construction Conference: 3 r?,( 22 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 ❑ No d. Management Program manual,including ORC contract,when applicable 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. 4. On-site Wastewater. Contractor name: \iUAnau ;lius���A1 1��, License number: 1 t./i ( Mailing address: ,�!41 7 lc.A Lk s,"ti �( 0.; ILIA City:S}-e.kA., State:h`., Zip:21. .i)?(, Telephone number: riC�'-yq -P�;13y E-mail Address:0 '41)44411.u1k5t,- rZ.-411�(-..ft_ rtek1 )•tl;w-‘ s. 5. Proof of Errors and Omissions or other appropriate liability insurance for the On-site Wastewater Contractor is att ed and includes the name of the insurer, name of the insured, and the effective dates of coverage. Yes ❑ No Attestation Oy the Owner for/�A thorization to Operate I, _ G� /iQrKS hereby attest that all items indicated above have been provided to the Print name of Owner County LHD and the system shall meet applicable federal, State, and local laws, regulation ,r es and ordinance . -- ,_ - -2/-,2O2Z— Signature of Owner Dote This section for LHD Use Only. LHD 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 L=1P 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). . i A copy of this complete NOi/ATO with tracking information was sent to the State on 51(11zz,via fi41 I, . Da Email,FAX,USPS,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. DHHS/EHS/OSWPB-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 l.(R"}Olo�i LHD Reference Number iss?... _(5) "7 Permitting backlog as of date of NOI submittal(#days) 35 Number of days to process the NOI(#days) 1i Number of days to process re-submitted NOI(#days or „`a "NA") !V 1 Facility type 3 Bat(op' -ROO e- Domestic,High Strength or IPWW Mf9t1 1. Design Daily Flow Si?D A pC) Residential or Commercial .eS; k n+;a� System type(per Rule.1961) la0 Date of Post-construction conference 3 1 2.l 2-2- Date Authorization to Operate issued 3 J LI 22- Fee charged for LSS COVID-19 $ RU 0 0 Is fee sufficient to cover LHD costs? e5 Date LHD notified of LSS COVID-19 malfunction r Date LHD notified of Owner complaint DNNS/ENS/OSWP—COVID-19 Appendix A Updated February 2022 Page 4 of 4 r k47- 3w -v- - 1 6wUv& �). -k,\, C-,vc,a) 3P-. N ^- Q-Ck_ D Q �g-0( i a 0--- vi zif5L. - i 21- \13 : 0 '14 .. 1 0 4a H N gii w u j x 1 14 To: Catawba County Department of Public Health Re: Signed Statement of Verification of Installed Septic System att/� Address: ��� '//s / fed., �4 &r4 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 otarized below. Owner Signature: Date North Carolina kc.Ue,4/10...Arn County I, -CA,Li l a Notary Public for j11QcLiPelv,,,e,County, North Carolina, do Hereby certify that_ S C k E, ilY11/04,S personally appeared before me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal, this the \ day of MeArC.X1 , 2022. nirrrrr \AEAL '' P• ON EXP)k. =Y; � � 2= Notary public: • • My expires: 10 -o� -ate y�y 9e J commission .°CTOB�� •� ,,C!,RrENB' INSTALLER CERTIFICATION Installer Name: C� N,L'JO( V6a0,- Address: I ' cii tl\C To: C County Department of Public Health Re: Signed Statement of Verification of Installed Septic System Lot: �� �� t \�C 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: Date 3 a'I- � 1, A ) IlitC.xvv 1i Erie CERTIFICATE OF INSURANCE DATE ISSUED(MM/DDrYY) Insurance® —THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY— 3/17/22 Home Office • 100 Erie Insurance Place • Ellie,Pennsylvania 16530 • 814.870.2000 Tog free 1.800.458.0811 • Fax 814.870.3126 • www.erieinsurance.com NAME AND ADDRESS OF AGENCY AGENT'S NO. C�Mpq�Y{�g p A��G COVERAGE SNIDER INSURANCE GROUP LLC C ERIE 1VSURAt�;FC �AN� _ 1438 WILKESBORO HWY JJ2072 __CO.: o'b�ERlE1NSl EEPRoPFRTv- E STATESVILLE,NC 28625 Co,;E brie Indemnn$NCGo.Attorrne-In-Fact of ApplYa e .,a.: S 111' II This certificate is issued for Information purposes only and confers NAME AND ADDRESS OF NAMED INSURED no rights on the certificate holder, It does not affirmatively or negatively amend,extend,or otherwise alter the terms,exclusions GROUNDBREAKER.1 GRADING INC and conditions of insurance coverage contained in the policy(ies) 207 MOUNTAIN VIEW RD indicated below.The terms and conditions of the policy(ies)govern the insurance coverage as applied to any given situation.Limits STATESVILLE,NC J8625-1269 shown may have been reduced by claims paid.This certificate of insurance does not constitute a contract between the Issuing insurer(s), authorized representative or producer and the certificate holder. This is to certify that policies,as indicated!Ate Policy Number below,are in force for the Named Insured at the time that the Certificate is bein issued. ..{,TRI ts1 TYPE OF INSURANCE POLICY NUMBER LIMITS E ❑GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 ❑X COMMERCIAL GENERAL LIABILITY Q4I 0153420 5/1/21 5/1/2 FIRE DAMAGE(Any One Fire) $ ❑CLAIMS MADE E OCCUR MED EXP(My One Person) $ 5,000 ❑ PERSONAL 8 ADV.INJURY § 1,000,000 ❑ GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AO$ 2,000,000 ®POLICY ❑PROJECT E LOG _ E ❑ AUTOMOBILE LIABILITY BODILY INJURY ❑ "ANY AUTO"(ND AFIIIRE ' Q05 0131816 5/1/21 5/1/22 (EACH PERSON) S ❑OWNED BODILY INJURY (EACH ACCIDENT) S ' ❑HIRED PROPERTY DAMAGE IS ❑ NON-OWNED BODILY INJURY AND 1 ❑ GARAGE PROCEMBIDERTY AAD GE Is 1,000,000 ❑EXCESS LIABILITY EACH OCCURRENCE $ ❑OCCURRENCE AGGREGATE $ ' iS ❑RETENTION S IS E WORKERS COMPENSATION& STATUTORY EMPLOYERS LIABILITY Q89 0102940 5/1/21 5!1/22 BODILY ACCIDENT $ 500,000 EACH ACCIDENT INJURY DISEASE $ 500,000 POLICY LIMIT _ BY DISEASE $ 500,000 EACH EMPLOYEE OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIV- ERED IN ACCORDANCE WITH THE POLICY PROVISIONS. IMPORTANT: If the certificate ho der 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). NAME AND ADDRESS OF CERTIFICATE HOLDER Earthwise Designs AUTH IZED RESE E 724 Duncan Rd Rutherfordton,NC 28139 EIG6230 8/11 Page 1 of 1 ACGROCERTIFICATE OF LIABILITY INSURANCE DATE{MM1DDlYYYY) 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 Hlscox Inc. PHONE FAX _VMC.No.Exq: (888)202-3007 — (ac,Ira): 520 Madison Avenue ADDRESS; contact@hiscox.com 32nd Floor — —— New York,NY 10022 INSURER(S)AFFORDING COVERAGE NAICN INSURER A: Hiscox Insurance Company Inc 10200 INSURED INSURER B; Earthwise Designs - 991 Duncan Rd INSURER C_ 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. INSR ADDL SUER--- POLICY POLICY EFF EXP LTR TYPE OF INSURANCE INED WVD_ POLICY NUMBER (I�AMU Y_YTTLA (YYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE NTED CLAIMS-MADE I OCCUR PREMISES0(EaEoccunenrej $ MED EXP jAny one Eaarson) $ PERSONAL E.AOV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE , -j POLICY JE LOC PRODUCTS-COMP/OP AGO $ i OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) —1 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY . AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _. AUTOS ONLY ,(Per accIeng_d —__ $ $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAR -- -- -- CLAIMS-MADE AGGREGATE__ $ OED RETENTIONS $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABRITY YIN -STAR ERH ANYPROPRIETORIPARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ OFFICERMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under I DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Professional Liability UDC-1571046-E0-21 04/20/2021 04/20/2022 Each Claim: $2,000,000 Aggregate: $2,000,000 DESCRIPTION OF OPERATIONS(LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more span Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD rl Earthwise Designs Soils do Land Evaluation 6/1/2021 Site and Soils Report with System Design Three-Bedroom SFH Wastewater System Lot 1, Subdivision of 5863 Sherrills Ford Road Catawba Co. NC 2.0 acre For Bobby and Jaycee Dedmon This report is submitted under the rule: , tea$(.0 4o. ,re�.eo '1r LSS COVID-19 PERMIT pursuant to S.L. 2020-97, '" 1 Section 3.19 and G.S. 130A-336.2 PART 1: Submittal of Notice of Intent to Construct (NOI) Earthwise Designs has performed a soils and site evaluation of the lot referenced above. We have found the lot Provisionally Suitable for the following system: 3-bedroom III g. gravelless trench system with 25%reduction, gravity fed. Details are discussed below and in the attached documents. Public water will be used. System Recommendations Initial and repair systems: III g. gravelless trench system with 25%reduction. Gravity fed, using distribution box with an at-grade access riser such as Polylok. • Soils: Group IV Silty Clay • Recommended LIAR: 0.25 (See detailed soil descriptions.) • Line length required=360'. Three 120' lines laid out for both systems. (See site plan.) • Trench width 36". • Trench bottom: 28"on downhill side. • Septic tank: 1000 gallons. • Note:repair may require new D-box placed near repair lines,minimum 5'off of deck and 5' off home foundation. Sufficient space exists for this,with supply line from septic tank re-routed along bottom corner of house. Other site-specific requirements: 1. We recommend the distribution box and system be inspected every 2 years by a private inspector. • 2. Heavy machinery over the drainfield area should be minimized before installation and avoided afterward. No structures or roads can be placed there. 3. 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. 4. Earthwise Designs makes no guarantees regarding installation, maintenance and operations. System design recommendations may not be accurate if site alterations occur prior to permitting and installation. Thank you and please contact me for further information, if needed. Caroline J. Edwards SOIL s NC Licensed Soil Scientist #1220 �°e fo SC Professional Soil Classifier #117 NC Land Application of Bio-Solids #10006173 (` `pn\ � DES t.. 3,1 Attachments: d4h, 1220 Site Plan 2 ps. cl`NroaM Soils sheet Preliminary Plat EARTHWISE DESIGNS 991 Duncan Rd Rutherfordton, NC 28139 Ciedwards234Ca�amail.com 828)289-0122 cell 7 a oa :it p( 6 � V. ki• 44 j 4 j4 � N • • `„-°' ' Earthwise Designs Site Plan Lot 1 ,....,---.2,- Soils and Land Evaluation Subdivision of 5863 Sherrills Ford Rd. Catawba Co.NC April,2021 ` Eq OS IL S�,E gy p.' See written report for system details. ~�� N �� �'v� Layout performed on 9'centers. • �a^.' B=Blue flagging stakes;Y =Yellow;P=Pink. 4. 1220CY' Double stakes mark the end of lines. 4 Additional blue and white stripped flagging mark the end of initial and beginning of repair. House corners marked with wooden stakes and orange cones. Darkened squares number 1-3=pit locations. Do 4-+-A-cti-Pl> c©' Additional triangulated measurements from fixed points: (R=existing rebar at fence comer. - 1 d\(Ai U V l E IA/ W4=4'white oak;W3 =3'white oak) Pit 1 =63'from R, 151'from W4 Pit 2= 133'from R,258'from W4 Pit 3=62'from W4, 113' from W3 • = 24-4 s O , ACC . Ill �2•rc►.y K6pr NPA.Z21&f ly 1 4rp ala=:--•'S v .4�`�- S �?•v -� ''._a•%I..,...r fr'-4._r` .// ,J� _ I le�q�r JtiT1 lts 3 J2t7 bi;or 3 5=.;,i Z:4.:.-i~- IbC *Iv I. 2 , . , ....,,..,.. __. _ ..,N.-,7......:7' .-. - • . 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