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HomeMy WebLinkAboutLSSP-05-2022-172487.TIF , ' 1573 hiu- 01 , , • COVIO-19 Permit Option Common Form LHD Reference: 1 J -U S-ZUGZ- )72 -(8' PART 3; Authorization to Operate(ATO) p,p_,P 12-lam'S')0» -II /15-v Except tor date received,the Section below is to be completed by the Owner. LHD USE ONLY: Initial submittal of request for ATO received: 1'1 -1&- 2 lz by r �o re initials Date of Post-construction Conference: The following Items are Included in this submittal for an Authorization to Operate under an LS5 COVID-19 permit: 1. Signed and sealed copy of the LSS's report that includes the information in G.S.130A-336.2(k) 'Yes ❑No 2. Operation and management program ['Yes ❑No 3. Fee (as applicable) 'Yes ❑No 4. Notarized letter documenting Owner's acceptance of the system from the LSS [0 Yes (-1 No Butler Bros Backhoe Service 8300 r �- S. On-site Wastewater Contractor name: License number: V` Mailing address: 3964 Old NC e City: Morganton State: NC Zip: 28655 v Telephone number: 828-439-3101 __ _ __ E-mail Address: Not available _ C; J 6. Proof of Errors and Omissions or other appropriate liability insurance for the On-site Wastewater Contractor is `y,, attDched 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 I, 3,C V\ J -\ �. \{ L.IL hereby attest that all items indicated above have been provided to the Print name of Owner J C> c'J)\(�tX County LHD and the system shall meet applicable federal,State,and local laws, regulations,rules,and ordinances. tot a.Joyce Apr 22,2023 Signature of Owner Date This section for DID tlse Only. LHD Review of required information for the MO ❑ INCOMPLETE Based upon review of Information submitted 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 1HD Signature of authorized Agent of the LND Dote [COMPLETE Based upon review of information submitted in the Section above,this Authorization to Operate Is hereby Issued In accordancewith G.S. 130A-336.2(m). A copy of this complete NOI/ATO with tracking information was sent,o the State on 5 31I "-Ai I, L3 via h►i A• ( . JJ pppaaa444 Emo71,FAX,WI Hand-delivered briA � � r— f f-26-23 Print name of authorized Agent of the LHD Signature of authorized Agent of the LND Date ISSUANCE OF CERTIFICATE OF OCCUPANCY: Once the IND 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/OSWP—LSS C-19 COMMON FORM Updated April 2022 Poge 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 Caitoti IA LHD Reference Number Mr- 05-2022-)729157 Permitting backlog as of date of NOI submittal(#days) 35 a o j s Number of days to process the NOI(#days) LI do15 Number of days to process re-submitted NOI(#days or ,i A "NA") Facility type 3 Bedro;lM 4 o Domestic,High Strength or IPWW DoMeC Design Daily Flow 360 qpa Residential or Commercial p OIueS`y11Q T['±A,11 System type(per Rule.1961) 3E5 Date of Post-construction conference w 1 Y ed Date Authorization to Operate issued 5 2i,123 Fee charged for LSS COVID-19 ties $90.60 Is fee sufficient to cover LHD costs? le, // Date LHD notified of LSS COVID-19 malfunction Date LHD notified of Owner complaint DHHS/EHS/OSWP—COVMD-19 Appendix A Updated February 2022 Page 4 of 4 • Earth wise Designs Soils& Land Evaluation 4/25/23 Robbie Phelps, REHS Environmental Health Supervisor, OSWP Division 25 Government Drive, Newton, NC 28658 'Re: Request for ATO for 1573 Berkshire Dr. Hickory; LSSP-05-2022-172487. This letter is to 1) Request to not have the On-site Post-Construction Meeting; and 2) Please see attached Final Documents with a Request for ATO for 1573 Berkshire Dr. Hickory; Ref#LSSP-05-2022-172487;and Management Manual. Please contact me if you have any questions; thank you very much. Sincerely yours, Caraffne J. warms �otp$C1( SAS 1.ED MG g I l NC Licensed Soil Scientist#1220 SC Professional Soil Classifier#117 %q,, ,, NC Land Application of Bio-Solids #10006173 To: Catawba County Department of Public Health Re: Signed Statement of Verification of Installed Septic System at Address: 1573 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 pres�cljt, npt rilzed below. 1 Owner Signature: ` Date L 2 ~ Z 3_ North Carolina C_rt G'.AyiG County I, B../R/2 ,jec'► a Notary Public for 4,4c� County, North Carolina, do Hereby certify that A A J('n Sp'K-c personally appeared before me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal, this the 2b day of 1f r' I , 2023. 4.a� Bto� Notary public: ; ------------- Notary My commission expires: ©? ,�fD-e ,ct Public V �°4 Cou�`�� • 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 1 NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR 1 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 (MMIDDIYYYY)(MM/DWYYYY) I 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 GEM_AGGREGATE APPLIES PER EACH OCCURRENCE $1,000,000 POLICY DAMAGE TO RENTED $100,000 PREMISES (Ea Occurrence) MED EXP (Any one person) $5,000 u BUSINESSOWNERS EACH OCCURRENCE AGGREGATE AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I SCHEDULE AUTOS (Each accident) I I HIRED AUTOS BODILY INJURY (Per person) u NON-OWNED AUTOS BODILY INJURY (Per accident) Li GARAGE LIABILITY PROPERTY DAMAGE u ._. (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 F NC E.L.E DISEASE - POLICY LIMIT 11 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 f(� t/ L f la ,�,,( ki COI 0910 C .--72.ec-,-• 1 ..\\ V\J & • t S 'el -f ----' LC I 2 i ' gR ,i4 ,-;/.... :itT. • 4-2.., ----,_ 150: iI Tu. _,.c. _9 -------;‘ - ---, *4 1 4 i_______-_-?54-a-- re „----.61.. , co i If --et.4 47224 ,CPI 1 • r ---Pa- v, .. 4' :1.4 • li Li' /1.2.1. ...,„.....,,............4 4,,, .. w, 1 X re ' . 1 * " C? e1/4, ..,N4e fol ---- _______L-3:"R . . il I ttN. / .1\ ti 1 ....i„..,,,---7--__ : . v • II j,. '''''" 21:tit -.(7f:::::-.7.- ' .. !J li ' 1 4- ''''''At ,: „ "-, 1 , .. - y -----_____ iii "I" II l c-1 Powv- Pole " . 2. -* -• i 4,f fe hee ,p 5)tsoa stv . . ,fr BETHEL CHURCH Ro (' . tO 'Prs..4,Atsz, /00.29 --------____ ----...._ -----___ 0 1 irr=40ft \ Parcel: 370005082892, 1573 BERKSHIRE DR HICKaty,,Ara apisw..- .4........„,----,.... Owners: R A JOYCE INVESTMENTS LLC, • Y Septic stem State University Owner's Guide N -Ar State University COOPERATIVE EXTENSION So i I F a e t s mom Empowering Pvoplc Providing Solutions If you use a septic system, or if you are buying a home with a septic system, this owner's guide can help you be sure that your septic system is used and maintained properly. This folder also provides a place to record and keep important information, such as a copy of your permit, a sketch of your system, maintenance records, and other fact sheets. Know the Ins and Outs of Your System For this reason, state rules have specific maintenance requirements for a number of these more sophisticated What type of system do you have? technologies. Often, homeowners will be required by Many different kinds of septic systems are used in North state sewage rules to hire a state-certified operator to Carolina, but most of the nearly 2 million systems in regularly inspect and maintain the system. In addition, state use throughout the state are slight modifications of the rules also require the health department to inspect these conventional septic system. This system has a septic tank systems on a periodic basis. and a drainfield with gravel-filled trenches (usually two to six trenches). Since the mid-to late 1990s, the traditional Your local health department can tell you what type of gravel aggregate trenches used in the past have given way system you have and what the legal requirements are for to newer gravel-less trench designs. long-term maintenance. These gravel-less trench designs rely on alternative Do you know the location of your septic system and materials in place of the gravel. The most common gravel- repair area? less trenches now used include either long, narrow, tunnel- To properly maintain your septic system, you should shaped chambers in the trenches or gravel substitutes know the location of both the septic tank (and any other such as expanded polystyrene aggregate. pretreatment units) and the drainfield. Contact the local health department for a copy of your septic system Other alternative trench materials that are being used permit and soil evaluation sheet. These forms indicate the in some parts of the state include large diameter pipe, approximate locations of each of the system's components permeable concrete blocks, and even recycled rubber tires and the size of the septic tank. Keep these items in this chopped into chips or pieces of a specific size. Septic System Owner's Guide file folder. Cooperative Extension Service publication AG-439-13, The location of the septic tank and drainfield can usually Septic Systems and Their Maintenance, describes the be determined with a copy of the permit and with the conventional system, simple modifications of it, and help of a septic contractor, consultant, or the local health important maintenance needs. department. Other more sophisticated types of on-site systems used Most housing sites permitted since the early 1980s are for the last 20 to 25 years include systems with pumps, legally required to have a "repair area or replacement area" mechanical pretreatment units, or biofilters. These in which a second drainfield could be built if needed.This technologies are now being used in numerous new housing repair area was identified by the health department when developments or to replace or repair failing septic systems the site was permitted and should be shown on your septic at homes and businesses. Systems using these new system permit. The law also requires you to protect this technologies require a higher level of maintenance than the area from excavation; building a house addition, garage or more traditional conventional septic systems. outbuilding over it; swimming pool construction; and any soil disturbance activities. • How old is the system? Things You Need to Know About Your Septic System • Where are the tank and drainfield located (they may • What type of septic system do you have? not be at the same location or even on the same • Where is it located? lot)? • Where is the repair area located? • When was the tank last pumped? ■ Is the septic system working? • How frequently has it been pumped? Has it been maintained in the past? • How often has the "effluent filter" in the septic tank ■ been cleaned (these effluent filters are required on • What can you do on a day-to-day basis to keep systems installed since 1999). your system working properly? • • Have there been signs of possible failure? • What maintenance is needed in the future? �..._._: • Where is a copy of the permit and records showing how well (or poorly) the system has been Sketch your home, septic system (both the tank and maintained? drainfield), repair area, and other important features (such • Have there been additions made to the house that as your driveway) on the grid labeled Septic System would necessitate increasing the size of the system? Layout. When you have your septic tank pumped, measure and record the distance from the house to the • Has the system ever been repaired, and if so, when, access port on the tank.This will help you find it again" and by whom? You might also wish to mark your tank location and the drainfield boundaries in your yard. If a riser is not If the house has just been built, ask the septic system installed over the access port for your septic tank, you contractor to provide you an "as built" diagram that may want to have one installed. Be sure, though, that may show details not on the permit. If the house has the riser is secured with a lock or a heavy lid to prevent a system with a pump, ask the contractor and health children from opening it and endangering themselves department to provide details concerning the initial pump or others. Even properly operating septic tanks contain setup. poisonous gases and pollutants as well as bacteria and other germs that can cause serious diseases. NO ONE Proper care of your septic system requires day-to-day SHOULD EVER ENTER A SEPTIC TANK. management as well as periodic maintenance and repairs. Is your septic system working properly? Septic System Layout Unfortunately, if house fixtures drain well, few people investigate whether • their septic system works. Many people don't realize that untreated sewage on top of the ground can be a health hazard. If your system shows signs of problems, contact your local health department immediately. State law requires that you get a permit from the health department before repairing a failing septic - ._ • system. Be wary of any contractor who wants to attempt a repair without a permit. What maintenance has been done? Before planning a maintenance program, find out what maintenance _ has already been done. If you are buying an existing home, ask the seller a few important questions: Day-to-Day Management • Cut down and remove trees that like wet conditions. This includes willows, elms, Don't use too much water. sweetgums, and some maples. • The drainfield does not have unlimited capacity. • Landscape the yard to divert surface waters away • Typical daily water use is 50 gallons per person. from the tank and drainfield. • The soil drainfield usually has a maximum daily • Be sure that the water from the roof, gutters, and design capacity of 120 gallons per bedroom, even foundation drains does not flow over the system. for short periods of time. • If your system is at the base of a slope, then • Overloads can occur seasonally, daily, or on the consider installing a french drain to divert weekend. underground waters. • Repair dripping faucets and toilets. • Maintain drainage ditches, subsurface tiles, and • Water conservation will extend the life of your drainage outlets so that water can flow freely from system. them. Limit disposal to sewage. Septic tank: • Don't use your septic tank as a trash can for • Install risers over the tank if it is buried 6 inches or cigarette butts, tissues, sanitary napkins, cotton deeper. They provide easy access for measuring swabs, cat box litter, coffee grounds, or disposable and pumping solids as well as cleaning the effluent diapers. filter. • • Restrict the use of your garbage disposal. These Measure how quickly sludge and scum accumulate add quite a lot of extra solids. in the tank. Have your professional pumper record this information. • Don't pour grease or cooking oil down the drain. • Have solids pumped out of the tank as needed. • Don't poison your system with harmful chemicals, Most septic tanks have two compartments; get such as solvents, oils, paints, thinners, discarded both pumped. medications, disinfectants, pesticides, poisons, and other substances. • Cooperative Extension Service publication AG- 439-13, Septic Systems and Their Maintenance, • Save money. Commercial septic tank additives are contains more information on pumping frequency. usually not necessary. • Don't wait until your drainfield fails to have your tank pumped. By then, the drainfield may Protect the system from physical damage (site be ruined. With septic systems, an ounce of maintenance). prevention is worth a ton of cure! • Keep the soil over the drainfield covered with vegetation to prevent soil erosion. Regulations and precautions: • Don't drive vehicles over the system. • Hire a state-certified subsurface system • Avoid construction over the system and repair operator for any system with a pump. One will area. be required by law for low pressure pipe (LPP) Maintain the natural shape of the land immediately systems installed or repaired after July 1, 1992, • downslope of the system, and protect this area any subsurface drip irrigation systems, aerobic from excavation (cutting and filling). treatment units (ATUs), peat biofolters, sand biofilters, textile biofilters, and other complex • Don't cover the tank or drainfield with asphalt or systems. concrete. • A list of state-certified subsurface system operators can be obtained from the N.C. Water Dispose of all wastewater in an approved system. Pollution Control System Certification Commission • Don't put in a separate pipe to carry wash waters at (919) 707-9089. to a side ditch or the woods. This is illegal. • Be sure the pump and electrical components continue working properly between scheduled Periodic Maintenance and Repair maintenance visits. Home and yard (site maintenance): • Sewage contains germs that can cause diseases. • Protect and maintain the site of your septic tank Never enter a septic tank. Toxic and explosive and drainfield. gases in the tank present a hazard. Old tanks Preventative Maintenance Record • may collapse. Electrical controls Work Done - Cost present a shock and spark hazard. Secure the septic tank lid so that children cannot open it. • Don't attempt to repair a failing — - system yourself. Get a repair permit and hire an experienced contractor. For more information about septic — — systems, contact your county — Extension agent or local health Your Septic System Pumper department. Name Acknowledgements Address Phone This publication is a revision of an earlier version. Your Septic System Installer Name Leonard Butler Appreciation is extended to Tom Konsler Address 3964 Old NC 18 Morganton (Orange County Health Department), Deanna Osmond, Mitch Woodward, Phone and Grace Lawrence (North Carolina Date System Installed April 2023 Cooperative Extension) for peer review of the document and to Debra Ireland for graphic design, layout, and editing. Signs of Possible Septic System Problems - ■ Sewage backing up into your toilets, tubs, or sinks. Authors: Michael T.Hoover • Slowly draining fixtures, particularly after it has rained. Extension Soil Science Specialist • The smell of raw sewage accompanied by soggy soil or sewage Department of Soil Science North Carolina State University discharged over the ground or in nearby ditches or woods. ■ Note: pump systems sewage may come to the ground surface when Edited by the pump is turned on and then disappear after the pump turns off. Jonathan Godfrey This is still a system failure and must be repaired. Director Onsite Wastewater Training Program • An alarm flashing (red light) or beeping in the house or in the yard Department of Soil Science indicating a pump is not working properly or that the water level in a 1 North Carolina State University pump tank is too high and close to failure. Published by: • An increase in infections or illnesses associated with swimming in North Carolina Cooperative Extension lakes or rivers next to the system. Service mod.d. NC STATE UNIVERSITY College of Agriculture and Life Sciences 5,000 copies of this publication were printed at a cost of$2,265 or$0.45 per copy, Distributed in furtherance of the acts of Congress of May B and June 30,1914.North Carolina State University and North Carolina A&T State University commit themselves to positive action to secure equal opportunity regardless of race,color,creed,national origin,religion,sex,age,veteran status,or disability.In addition,the two Universities welcome all persons without regard to sexual orientation.North Carolina State University,North Carolina A&T State University,U.S.Department of Agriculture,and local governments cooperating. 5/2016-5M—DI (Revised) AG-439-22 content.ces.ncsu.edu/septic-system-owners-guide ©2016 North Carolina State University •S1N3WWOO Co' E'0 NIV11•MS ueweaij uossyy g leu6eM patio :1013S321d(S)2:13H1O 031d3O3V 031d333V '(s)sedAj walsAS sueBoa dalysv :A8 031Vf11VA3 Sd Sd (94611 eaedg elgepeny Sd :I8461')NOIiVOIAISSV1O 311S :I8461')S2JO1OVA 83H1O W31SAS 2JIVd321 W31SAS 1VI11Nl NOIldI S30 p 1f ON 9Z£0-E•I •dam / i' • I I -``' 0 • dVSJ dSSS d NBSdM1O8a 09-6Z %ZLn 6 '''lJ.e dSSS d ASSWMOa9 6Z-L r }1 s !' f� dSSSM J )8SdM1OS92J L o N i /3 • dVSd dSSS2d )IBSdM1O82 6S-8E L .; a r�E'0-S• dSSS8d )48SWMOH8 8E-OZ %OLn 9 '{ /7-444^' ,\' 7 dSSS2JJ )18SdM1OS82J OL-EL b f '� O382Jf11SIOnlld EL-0 f ? £'0-Sd S ^/ I 0`_) .' • dVSd d5SS2ld WBSdM1O82! 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L ..,..—. ` dSSSIIA )(SSWM02JB 94-91. , dSSS2Jd N0SdM13S9 91.-0 dVSA dSSSMd N9SdM1O82J O9-04 £'0-Sd K dSSS2Jd )19SWMOH9 04-61 %6n 9 dSSS2Jd N0SdM10S9 61.-b1 O386111SI0nlid 1,1-0 dSSS2Jd SSVWIS24VA 09-6£ SZE'0-E'0-Sd 6E NM/dVSO dSSS8d N8SdM1O82J 6£-4Z %9n S dSSS2Jd N8SWM3219 4Z-L dSSSNd )19SdM1O2l8 L-0 dVSd dSSSbld )18SdM1O9d 09-04 CO-Sd 101, dSSSeld N9SWM088 O4-LI %Ln 4 dSSS2Jd )4SSdM1OS9 LL-OL _ 0382Jl1SI0nlId 01-0 E'0-Sd 09 dVSd dSSS2Jd N6SdM1O82J O9-LC %Bn C dSSSMd NBSWMO2J LE-9L dSSS8.4 N8SdM139N 91-0 dVSd dSSS2Jd N8SdM1O82J O5•04 E0-Sd 9£ dSSSiJd N9SWMO2J8 _ 04.6E %9n Z dSSS2dd NSSdM1OS8 6L-4L O392Jl1S10nhId 41.-0 E'0-Sd 9E dSSSMd NBSWMONB 09-61 %Lf1 L dSSS'dd N8SdM10921 61-41 O392Jl1SI0n1H 41-0 UV IVJ # ZIMOH SSV10 H1d3O ISS3N13M AJO1Vd3NI1.11 3Mf11X31 2J1S38 MdVS 11OS 11OS I3ON31SISNOO I3ilfIOld1S 4461.' 9S61' £461' Z461' 1461' 1461' %3dO15 3 MVIA g ('NI) 1/NOIlISOd SSV1O H1d3O 1 3dVOS0NV1 31IdO2Id SNO1OVd 311dO2Jd (14611 NOZI2JOH O461. d 2J3H1O ADO1OHd2JOW 11OS 0 2I d pexiW ❑ ssa3OJd leulsnpul ❑ e6eMOS ❑' :2I31VM31SVM dO 3dAl ln3 0 lid 0 Buimg JaBny 0 :0OH13W NOI1Vf1lVA3 aeglO❑ Bupds❑ II°M ❑r elenl.d❑r :AlddflS 2I31VM papiooal aq of-ou :O3021O032J A1213dO8d VZ#101 pasodoJd-Z999Z ON IIa»al al pOOAnU39 49E0 :311S dO NOI1VOO1 os E96'0 :321S A1213dOdd aouepisai wooipaq 4 :A1I11OV4 O]SOdO2id EZOZ/OUE :O31V111VA3 31V0 029Z ON 4111ogieg01S alepsu!H 9ZLZ :5S32J0OV :311/0 NOI1V011ddV au009 lalleM :83NMO (IInI ul spleI lie eleidwoa) W31SAS 2J31VM31SVM 311S-NO J04 NOLLVf11VA3 311Sf11OS egMele3 :A101f1O0 09EE6SZ09L90 :#01 Al2J3dO2Jd I /o L 7a94S Robert Phelps From: Robert Phelps Sent: Thursday, May 25, 2023 4:11 PM To: 'Caroline Edwards' Cc: ron joyce Subject: RE: Request for ATO Ref#LSSP-05-2022-172487 R Joyce Caroline, The ATO you have submitted for 1573 Berkshire is incomplete. Item 4 on the ATO form is missing. -Item 4: the notarized letter documenting the owner's acceptance of the system from the LSS. Please send this information and we can mark the ATO complete. Thank You Robbie Phelps, REHS Environmental Health Supervisor, OSWP Division 25 Government Drive, Newton, NC 28658 (828)320-3077 cell https://www.catawbacountync.Rov/county-services/environmental-health/ Catawba county Confidentiality Statement:The information contained in electronic transmissions is confidential and may be subject to protection under the law,including the Health Insurance Portability and Accountability Act(HIPAA).An electronic transmission is intended for the sole use of the individual or entity to whom it is addressed.If you are not the intended recipient,you are hereby notified that any use,distribution or copying of the message is strictly prohibited.If you received a message in error, please contact the sender immediately by replying to the e-mail and delete the material from any computer. From: Caroline Edwards [mailto:cjedwards234@gmail.com] Sent: Wednesday, April 26, 2023 1:58 PM To: Robert Phelps<RPhelps@CatawbaCountyNC.gov> Cc: ron joyce <rjoyceconst@gmail.com> Subject: Request for ATO Ref#LSSP-05-2022-1.72487 R Joyce To: Robbie Phelps, REIN Environmental I lealth Supervisor. OSWP Division 25 Government Drive, Newton, N(' 28658 Please see attached Final Documents with a Request for ATO for 1573 Berkshire Dr. Hickory; Ref#LSSP-05-2022-172487; and Management Manual. Let me know any questions, and thank you for expedited action. Best regards, Caroline J. Edwards NC Licensed Soil Scientist#1220 Authorized On-site Wastewater Evaluator#10035E NC Land Application of Bio-Solids #10006173 SC Professional Soil Classifier #117 EARTHWISE DESIGNS 991 Duncan Rd Rutherfordton, NC 28139 828)289-0122 cell. Cjedwards231 c,gmail.corn 2 Lfrp._ 172 47 ROY COOPER •Governor g, i NC DEPARTMENT OF ::: : ::tterim .KINSY• ary HEALTH AND HUMAN SERVICES Deputy Secretary for Health y�,,. MARK T.BENTON•Assistant Secretary for Public Health QW 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: S'—Z11 —2-2— by fie Date Initials PART 1:Notice of Intent to Construct(NOI)-Please check all that apply ®Single System or ❑ Multiple Systems AND New ❑ Expansion ❑ Relocation of all or part of the Existing System ❑Relocation of Repair Area ❑ Repair—LHD Permit Number ❑Repair—EOP/LSS COVID 19/AOWE Permit Number 1. Facility Owner's name: (Owner,Company Name,Utility, Partnership,Individual,etc.): Ron Joyce Mailing address:PO Box 716 City:Hickory State:NC Zip:28603 Telephone number: 828-381-2520 E-mail Address: rjoyceconst@gmail.com 2. Licensed Soil Scientist(LSS)name:Caroline J.Edwards LSS License number: 1220 Mailing address: 991 Duncan Road 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: LSS ❑ LG 5. Property location(physical address,tax parcel identification number or subdivision lot,block number of the property to be permitted):1573 Berkshire Dr Hickory 28602 County Name: Catawba 6. Type of facility: ® Place of residence No. Bedrooms: 3 No.Occupants:2 El 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:919-707-5874 • FAX:919-845-3972 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER COVlD-19 Permit Option Common Form LHD Reference: ^J °5 —Z °L2- 7Z`1'9 ? 7. Factors that would affect the wastewater load: None 8. Type and located of proposed wastewater system: lilg From driveway, left of house on southeast 9. Design wastewater flow: 360 gpd Design wastewater strength: ®domestic ❑high strength El industrial process(For industrial process wastewater,o 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 11. 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 12. Evaluation(s)of soil conditions and site features in accordance with G.S.130A-335(al)signed and sealed by a LSS is attached: ®Yes ❑No 13. Evaluation of geologic and hydrogeologic conditions signed and sealed by a LG is attached El Yes ®NA 14. Proposed landscape,site,drainage,or soil modifications are attached: ❑Yes ®NA Attestation by LSS pursuant to S.L 2020-97,Section 3.19 and G.S.130A-336.2 I, 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 15A NCAC 18A.1938 and activities determined to be engineering as determined by the North Carolina Board of ExaQZiners for Engineers and Surveyors. Signature of Licensed Soil Scientist Date Owner self-submittal of NO1: hereby submit this NOI prepared by Print Name of Owner Print Name of Licensed PE pursuant to G.S.130A-336.1. Signature of Owner Date DHHS/EHS/OSWP—LSS C-19 COMMON FORM Updated April 2022 Poge 2 of 6 • COVID-19 Permit Option Common Form LHD Reference: 1—S`CP— 0 2 o 'i-1724 y7 NOTES: LIABILITY: The Department,the Department's authorized agents,or local health departments shall have no liability for wastewatersystems designed,constructed,and installed pursuant to an LSS COVID-19 Permit Option(S.L.2020- 97,Section 3.19(d)and G.S.130A-336.2(f)) 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/OSWP—LSS C-19 COMMON FORM Updated April 2022 Page 3 of 6 • COVID-19 Permit Option Common Form LHD Reference: `J T/ ' vS 2DL2-(724 7 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 deportment 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 deportment 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 Date 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 L55 end the Owner on l-Z7-2'via lr'146 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 14/04, Print Name of Authorized Agent of the LHD Signature of Authorized Agent of the LHD Date DHHS/EHS/OSWP-LSS C-19 COMMON FORM Updated April2022 Page 4 of 6 COVID-19 Permit Option Common Form LHD Reference: `'S rir -0' 2 U LZ-) 72 4" 7 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 Dote Initials Item tI from initial NOI Resubmittal description Attestation by LSS pursuant to S.L.2020-97,Section 3.19 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,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 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 LHD Date DHHS/ENS/OSWP—LSS C-19 COMMON FORM Updated April 2022 Page 5 of 6 COVID-19 Permit Option Common Form LHD Reference: Lv fp v S-�G2- 7� 8 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: by Date initials Date of Post-construction Conference: 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 the information in G.S.130A-336.2(k) ❑Yes ❑No 2. Operation and management program ❑Yes ❑No 3. Fee (as applicable) ❑Yes ❑No 4. Notarized letter documenting Owner's acceptance of the system from the LSS ❑Yes ❑No S. On-site Wastewater Contractor name: License number: Mailing address: City: State: Zip: Telephone number: E-mail Address: 6. 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 I, 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, regulations,rules,and ordinances. Signature of Owner Dote This section for LHD Use Only. CND Review of required information for the ATO ❑ INCOMPLETE Based upon review of information submitted 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 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 sent to the State on via Dote 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/OSWP—LSS C-19 COMMON FORM Updated April 2022 Page 6 of 6 AC RE CERTIFICATE OF LIABILITY INSURANCE DATEIMMDD/WYY) `.� 03/06/2022 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 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. PHONE FAX 520 Madison Avenue (A/C.No.Extr (888)202-3007 (A/C,No): E-MAIL Contact hiscox.com 32nd Floor ADDRESS: New York,New York 10022 INSURER(S)AFFORDING COVERAGE NAICif INSURERA: Hiscox Insurance Company Inc 10200 INSURED INSURER B Earthwise Designs 991 Duncan Rd INsuRERc: 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 TYPE OF INSURANCE ADDL SUER! POLICY EFF POLICY EXP T LIMITS LTR+ INSQL WVD i POUCY NUMBER ,MM/DDIYYYY)� YI IMM(DD/YYY COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE S _ —j I CLAIMS-MACE OCCUR DAMAGMAGSTOTO RENTED PREMISES(Ea occurrence]_ $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ POLICY Li PECTR0 LOC PRODUCTS-COMP/OP AGO $ • OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ _(Ca accident) _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED I SCHEDULED BODILY INJURY(Per accident) $ AUTOS _ AUTOS NON-OWNED ! PROPERTY DAMAGE $ HIRED AUTOS AUTOS ddent) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION$ ! $ WORKERS COMPENSATION PER OTH- ANDEMPLOYERS'UABIUTY YIN STATUTE ER ANYPRCPRIETOR/PARTNERIEXECUTIVE - N/A - E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED7 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S dyes,describe under -- - -"—`--- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Professional Liability P100.217.339.8 04/20/2022 04/20/2023 Each Claim:$2,000,000 Aggregate:$2,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space 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 7, • • Earthwise Designs $!-- Soils &Land Evaluation 5/9/2022 Site and Soils Report with System Design Three-Bedroom Residential Wastewater System 1573 Berkshire Dr. Hickory NC 28602 .38 ac. Catawba County REID 606875 Prepared for: Ron Joyce Construction 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(NOI) Earthwise Designs has performed a soils and site evaluation of the lot referenced above. We have delineated an area that is Provisionally Suitable for a three-bedroom III g.gravelless trench system with 25%reduction—initial;PPBPS repair.Neither is a saprolite system. Water is provided by a local authority.Details are discussed below and in attached documents. System Specifications Initial: 3-bedroom III g. gravelless trench, Approved Accepted system with 25%reduction. Gravity fed with serial distribution. See site plan. • Soils: Group IV—Silty Clay • LTAR: 0.3 • Line length required=300' • Note: System will be installed by.Mr.Leonard Butler utilizing his method of distribution. • Trench width 36" • Trench bottom: 18-28"on downhill side of trench. • Septic tank: 1000 gallons Repair: III e. PPBPS(T&J Panel). Vertical installation. • Soils: Group IV—Silty Clay • LTAR: 0.3 • Line length required=200' u Four 50'lines on 8'centers. o Lines drawn on site plan,ample room exists-50'x 50'measured from setbacks. • Equal distribution utilizing d-box. • Gravity should be attainable. Otherwise,use pump system. • Trench width 36" • Trench bottom:28"on downhill side 2 Other site-specific requirements and notes: 1. No cut or fill can encroach on the drainfield area,initial or repair. 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. 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 SOIL NC Licensed Soil Scientist#1220 �``°J.F �F.y SC Professional Soil Classifier#117 'os> NC Land Application of Bio-Solids #10006173 ':vr Attachments: 1220 Site Plan in two pages of Atom Soils sheet EARTHWISE DESIGNS 99/Duncan Rd Rutherfordton, NC 28139 Ciedwards2340.amall.com 828)289-0122 cell p 1 fcV k"� Earthwise Designs 1573 Berkshire Drive, Caldwell Co. NC Soils&Land Evaluation .38 ac. REID 606875 May,2022 Legend and Notes for Site Plan See written report for additional details. • m g.gravel less trench with 25%reduction. • Soils—Group IV—Silty Clay • LTAR: 0.3 • Drain field lines shot on 9' centers and staked as indicated on site plan. P=pink metal stakes;Y=yellow. • R=PPAPS repair lines. • Circled dots 1-3 =pits. • All corners of house staked. Triangulated pit locations from fixed points: Cl&C2=property corners,see site plan. Pit 1:94'from Cl; 128'from C2 Pit 2:40'from C1;92'from C2 Pit 3:90'from CI;41'from C2 SOIL Sc., e0 . A »o 220.....) 10 k cata 4 e�cou y eirtf°s servicesReal Estate Search I i 10 4 r e r- f G-L -..-_`�- 1a(j,pp K I( 7 . .Gy Y S.f;.-.-:---- - /-.-d''4.4"_4_____ i"--t-----,cc,. 7',-. -1`t .5�_ V f, {gyp 1i E tr " d. iF of 0 �l - ir et I. !r @ a yQ �y -� _tr, d? G F PONar 2. plc.• 'kCC 40Qk `GEC J.qd � o �s • .' RCN % 1Q(j.29 'FACOi C gg_7 w�c 'i in=4f}€t 5 Parcel:370005082892, 1573 BER21-1 2DR HiitaaatiM Owners:R A JOYCE INVESTMENTS LLC, Owner Address: PO BOX 716 Values-Building(s): $O, Land:$24,400,Total:$24,400 This map/report product was prepared from the Catawba County,NC Geospaial lnfnmrafan Services. Catawba County has made substantial efforts to ensure the accuracy of location and labelina iMormation contained on The map or data on this report.Catawba County promotes and recommends the independent verification of any data cons ned on this map/report product by um user.The county of Catawba,tts employees,agents,and persorxret.sir,and shall not be held liable for array and all damages,boss to liability.whether direct,indirect or oonsequential which snaps or may arise from this maphepurt product orthe use thereof by any person or entity. Copyright 2021 Catawba County NC 04I1412022 li � �C,: Q"l • � �� off- � � <� __,___ _ __ ,,>,„. „,50„,. , ,„c„ .FE.2,_ 11P-4113-, NI n O v x; t ' 04 #- Jo a., o X I'h 1, w 1 T - i P. 1 Ti a • R ml @n >( r1j:iUfl � t N 2 E t., I t ki U ai 1-1 ki fl {}z ft UIY a et- f i� \` \�C t { ZC /-aa.maa4/ Eo, .*{ a C CI0 )Q1 " .i g ' P a Q i Ll g j 5:: ‘q. -,-,ta, LI I k, l! g Y I _ E a� � wa � wm t i a. c i _ QQ E i E 5 ES sG :Itia i Y 1 `` r In u p �,{� _ i E. y ��QIIU�mrod 2�1 r'_"3 +�+ t \ �f_ i = ' E. m sr.. Ohl_,P-Q w jii, y 4 h a. _ _ I o E ' G �� 14. ! a -gGI 1 a E tdtill u 'sr•fl HI1I1i#; uG I o u v w icy ' �p 4 (} �� T i / �`` Earth wise Designs Soils& Land Evaluation -1/25/23 Robbie Phelps, REHS Environmental Health Supervisor, OSWP Division 25 Government Drive,Newton, NC 28658 'Re: Request for ATO for 1573 Berkshire Dr. Hickory; LSSP-05-2022-172487. This letter is to 1) Request to not have the On-site Post-Construction Meeting; and 2) Please see attached Final Documents with a Request for ATO for 1573 Berkshire Dr. Hickory; 1 Ref#LSSP-05-2022-172487;and Management Manual. Please contact me if you have any questions; thank you very much. Sincerely yours, Caroline J. ards- W OSOlL3�P (‘( itV 4,POLV NC Licensed Sail Scientist #1220 SC Professional Soil Classifier#117a,.,, , NC Land Application of Bio-Solids #10006173 COVID-19 Permit Option Common Form LHD Reference: L.S rr— S-2UGZ` 172 PART 3; Authorization to Operate(A7O) Except for dote received,the Section below is to be completed by the Owner, LHO USE ONLY: Initial submittal of request for ATO received: by Dote initials Date of Post-construction Conference:— 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 the information in C.S.130A-336.2(k) Ekes ❑No 2. Operation and management program 'Yes ❑ No 3. Fee (as applicable) 'Yes ❑No 4. Notarized letter documenting Owner's acceptance of the system from the LSS [j Yes n No Butler Bros Backhoe Service 8300 5. On-site Wastewater Contractor name: License number: Mailing address: 3964 Old NC 18 City: Morganton State: NC Zip: 28655 Telephone number: 828-439-3101 E-mail Address: Not available 6. Proof of Errors and Omissions or other appropriate liability insurance for the On-site Wastewater Contractor is attEched 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 I, 3,0 V\. C::\( L--Q. hereby attest that all items indicated above have been provided to the Print name of Owner CKA(.12. ,-.:\f)t County LHD and the system shall meet applicable federal,State,and local laws, regulations,rules,and ordinances. Apr 22,2023 Signature of Owner Date This section for LHD Use Only. LHD Review of required information for the ATO ❑ INCOMPLETE Based upon review of Information submitted 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 Dote 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 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 sent to the State on via Dote Email,FAX,USPS Hond-delivered Print name of authorized Agent of the LiiD Signature of authorized Agent of the LHD Date ISSUANCE OF CERTIFICATE OF OCCUPANCY: Once the LHD determines completeness based upon the Aro submission,the owner may apply to the local permit-Imp agency for permanent electrical service to a residence,place of business or place of public assembly pursuant to G.S. 130A-339. DNHS/EHS/OSWP—LSS C-19 COMMON FORM Updated April 2022 Page 6 of 6 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 AODLSUBRPOLICY NUMBER POLICY EFF POLICY EXP LIMITS INSD WVD (MM/DD/YYYY)(MM/DD/YYYY) u COMMERCIAL GENERAL To be assigned 08/10/2022 08/10/2023 GENERAL AGGREGATE $2,000,000 LIABILITY -OCCURRENCE PRODUCTS- COMPIOPS $2 000,000 AGGREGATE PERSONAL &ADV INJURY $1,000,000 GENL AGGREGATE APPLIES PER POLICY EACH OCCURRENCE $1,000,000 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 o SCHEDULE AUTOS (Each accident) u HIRED AUTOS BODILY INJURY (Per person) o NON-OWNED AUTOS BODILY INJURY (Per accident) a 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 1 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 DATE j 01.,m DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. E ►►►///[[[ COI 0910 .J_w 5 -q 1.0,_6c Ck 7?.c-- % 3, & - 'I 51 'fin k5_>1(\k - \\J , Acv ,( ,. 4 2C- 12_ _ c . 61-kX.1r-AxkW JJI 41 1 ^ I 9` i ~ ci �, 150.00 ,.„ I ! _!:':S4iJ:2!& ^r p. _ frt. '41 . f wif 1: _F ti it II trot: g iII9, :_..ram of lrscc r'soa 8cifuRciien / 700.29 Avow "W+E 't ire-40€t s W Parcel:370005082892, a BBERKSHKS� I DR HIC �, Owners:R A JOYCE INVESTMENTS LLC, Septic System NC STATE UNIVERSITY State University Owner's Guide A&T StateUniversity COOPERATIVE �EXTENSION _ S O'I F a c`S Empowering People•Providing Solutions If you use a septic system, or if you are buying a home with a septic system, this owner's guide can help you be sure that your septic system is used and maintained properly. This folder also provides a place to record and keep important information, such as a copy of your permit, a sketch of your system, maintenance records, and other fact sheets. Know the Ins and Outs of Your System For this reason, state rules have specific maintenance requirements for a number of these more sophisticated What type of system do you have? technologies. Often, homeowners will be required by Many different kinds of septic systems are used in North state sewage rules to hire a state-certified operator to Carolina, but most of the nearly 2 million systems in regularly inspect and maintain the system. In addition, state use throughout the state are slight modifications of the rules also require the health department to inspect these conventional septic system. This system has a septic tank systems on a periodic basis. and a drainfield with gravel-filled trenches (usually two to six trenches). Since the mid-to late 1990s, the traditional Your local health department can tell you what type of gravel aggregate trenches used in the past have given way system you have and what the legal requirements are for to newer gravel-less trench designs. long-term maintenance. These gravel-less trench designs rely on alternative Do you know the location of your septic system and materials in place of the gravel.The most common gravel- repair area? less trenches now used include either long, narrow, tunnel- To properly maintain your septic system, you should shaped chambers in the trenches or gravel substitutes know the location of both the septic tank(and any other such as expanded polystyrene aggregate. pretreatment units)and the drainfield. Contact the local health department for a copy of your septic system Other alternative trench materials that are being used permit and soil evaluation sheet. These forms indicate the in some parts of the state include large diameter pipe, approximate locations of each of the system's components permeable concrete blocks, and even recycled rubber tires and the size of the septic tank. Keep these items in this chopped into chips or pieces of a specific size. Septic System Owner's Guide file folder. Cooperative Extension Service publication AG-439-13, The location of the septic tank and drainfield can usually Septic Systems and Their Maintenance, describes the be determined with a copy of the permit and with the conventional system, simple modifications of it, and help of a septic contractor, consultant, or the local health important maintenance needs. department. Other more sophisticated types of on-site systems used Most housing sites permitted since the early 1980s are for the last 20 to 25 years include systems with pumps, legally required to have a "repair area or replacement area" mechanical pretreatment units, or biofilters. These in which a second drainfield could be built if needed. This technologies are now being used in numerous new housing repair area was identified by the health department when developments or to replace or repair failing septic systems the site was permitted and should be shown on your septic at homes and businesses. Systems using these new system permit. The law also requires you to protect this technologies require a higher level of maintenance than the area from excavation; building a house addition, garage or more traditional conventional septic systems. outbuilding over it; swimming pool construction;and any soil disturbance activities. • How old is the system? Things You Need to Know About Your Septic System • Where are the tank and drainfield located (they may ■ What type of septic system do you have? not be at the same location or even on the same lot)? ■ Where is it located? ■ Where is the repair area located? • When was the tank last pumped? • Is the septic system working? • How frequently has it been pumped? • Has it been maintained in the past? • How often has the "effluent filter" in the septic tank been cleaned (these effluent filters are required on • What can you do on a day-to-day basis to keep 411, systems installed since 1999). your system working properly? • Have there been signs of possible failure? ■ What main dance is needed in the future?, ; .. . • Where is a copy of the permit and records showing how well (or poorly)the system has been Sketch your home, septic system (both the tank and maintained? drainfield), repair area, and other important features (such • Have there been additions made to the house that as your driveway) on the grid labeled Septic System would necessitate increasing the size of the system? Layout. When you have your septic tank pumped, measure and record the distance from the house to the • Has the system ever been repaired, and if so, when, access port on the tank. This will help you find it again. and by whom? You might also wish to mark your tank location and the drainfield boundaries in your yard. If a riser is not If the house has just been built, ask the septic system installed over the access port for your septic tank, you contractor to provide you an "as built" diagram that may want to have one installed. Be sure, though, that may show details not on the permit. If the house has the riser is secured with a lock or a heavy lid to prevent a system with a pump, ask the contractor and health children from opening it and endangering themselves department to provide details concerning the initial pump or others. Even properly operating septic tanks contain setup. poisonous gases and pollutants as well as bacteria and other germs that can cause serious diseases. NO ONE Proper care of your septic system requires day-to-day SHOULD EVER ENTER A SEPTIC TANK. management as well as periodic maintenance and repairs. Is your septic system working properly? Septic System Layout Unfortunately, if house fixtures drain well, few people investigate whether their septic system works. Many people don't realize that untreated sewage on top of the ground can be a health hazard. If your system shows signs of problems, contact your local health department immediately. State law requires that you get a permit from the health department before repairing a failing septic system. Be wary of any contractor who wants to attempt a repair without a permit. What maintenance has been done? Before planning a maintenance program, find out what maintenance has already been done. If you are buying an existing home, ask the seller a few important questions: Day-to-Day Management • Cut down and remove trees that like wet conditions. This includes willows, elms, Don't use too much water. sweetgums, and some maples. • The drainfield does not have unlimited capacity. • Landscape the yard to divert surface waters away • Typical daily water use is 50 gallons per person. from the tank and drainfield. • The soil drainfield usually has a maximum daily • Be sure that the water from the roof, gutters, and design capacity of 120 gallons per bedroom, even foundation drains does not flow over the system. for short periods of time. • If your system is at the base of a slope, then • Overloads can occur seasonally, daily, or on the consider installing a french drain to divert weekend. underground waters. • Repair dripping faucets and toilets. • Maintain drainage ditches, subsurface tiles, and • Water conservation will extend the life of your drainage outlets so that water can flow freely from system. them. Limit disposal to sewage. Septic tank: Don't use your septic tank as a trash can for • Install risers over the tank if it is buried 6 inches or • cigarette butts, tissues, sanitary napkins, cotton deeper.They provide easy access for measuring swabs, cat box litter, coffee grounds, or disposable and pumping solids as well as cleaning the effluent diapers. filter. • Restrict the use of your garbage disposal. These • Measure how quickly sludge and scum accumulate add quite a lot of extra solids. in the tank. Have your professional pumper record this information. • Don't pour grease or cooking oil down the drain. ■ Have solids pumped out of the tank as needed. • Don't poison your system with harmful chemicals, Most septic tanks have two compartments; get such as solvents, oils, paints, thinners, discarded both pumped. medications, disinfectants, pesticides, poisons, and other substances. • Cooperative Extension Service publication AG- 439-13, Septic Systems and Their Maintenance, • Save money. Commercial septic tank additives are contains more information on pumping frequency. usually not necessary. • Don't wait until your drainfield fails to have Protect the system from physical damage (site your tank pumped. By then, the drainfield may be ruined.With septic systems, an ounce of maintenance). prevention is worth a ton of cure! • Keep the soil over the drainfield covered with vegetation to prevent soil erosion. Regulations and precautions: • Don't drive vehicles over the system. • Hire a state-certified subsurface system • Avoid construction over the system and repair operator for any system with a pump. One will area. be required by law for low pressure pipe (LPP) Maintain the natural shape of the land immediately systems installed or repaired after July 1, 1992, • downslope of the system, and protect this area any subsurface drip irrigation systems, aerobic from excavation (cutting and filling). treatment units (ATUs), peat biofolters, sand biofilters, textile biofilters, and other complex • Don't cover the tank or drainfield with asphalt or systems. concrete. • A list of state-certified subsurface system operators can be obtained from the N.C. Water Dispose of all wastewater in an approved system. Pollution Control System Certification Commission • Don't put in a separate pipe to carry wash waters at(919) 707-9089. to a side ditch or the woods.This is illegal. • Be sure the pump and electrical components continue working properly between scheduled Periodic Maintenance and Repair maintenance visits. Home and yard (site maintenance): • Sewage contains germs that can cause diseases. • Protect and maintain the site of your septic tank Never enter a septic tank. Toxic and explosive and drainfield. gases in the tank present a hazard. Old tanks Preventative Maintenance Record • may collapse. Electrical controls Date Work Done Firm present a shock and spark hazard. Secure the septic tank lid so that — - children cannot open it. • Don't attempt to repair a failing system yourself. Get a repair permit and hire an experienced contractor. For more information about septic systems, contact your county l Extension agent or local health Your Septic System Pumper department. Name Acknowledgements Address Phone This publication is a revision of an earlier version. Your Septic System Installer Name Leonard Butler Appreciation is extended to Tom Konsler Address 3964 Old NC 18 Morganton (Orange County Health Department), Deanna Osmond, Mitch Woodward, Phone and Grace Lawrence(North Carolina Date System Installed April 2023 Cooperative Extension)for peer review of the document and to Debra Ireland for graphic design, layout,and editing. Signs of Possible Septic System Problems Sewage backing up into your toilets, tubs, or sinks. Authors: Michael T.Hoover • Slowly draining fixtures, particularly after it has rained. Extension Soil Science Specialist • The smell of raw sewage accompanied by soggy soil or sewage '. Department of Soil Science discharged over the ground or in nearby ditches or woods. North Carolina State University • Note: pump systems sewage may come to the ground surface whe Edited by the pump is turned on and then disappear after the pump turns off. Jonathan Godfrey This is still a system failure and must be repaired. Director Onsite Wastewater Training Program • An alarm flashing (red light) or beeping in the house or in the yard Department of Soil Science indicating a pump is not working properly or that the water level in a North Carolina State University pump tank is too high and close to failure. Published by: • An increase in infections or illnesses associated with swimming in North Carolina Cooperative Extension lakes or rivers next to the system. Service NC STATE UNIVERSITY College of Agriculture and Life Sciences 5,000 copies of this publication were printed at a cost of$2,265 or$0.45 per copy. Distributed in furtherance of the acts of Congress of May B and June 30,1914.North Carolina State University and North Carolina A&T State University commit themselves to positive action to secure equal opportunity regardless of race,color,creed,national origin,religion,sex,age,veteran status,or disability.In addition,the two Universities welcome all persons without regard to sexual orientation.North Carolina State University,North Carolina A&T State University,U.S.Department of Agriculture,and local governments cooperating. 5/2016-5M—DI (Revised) AG-439-22 content.ces.ncsu.edu/septic-system-owners-guide ©2016 North Carolina State University