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HomeMy WebLinkAboutLSSP-06-2022-172677.tif Zs 06 -20?- - / l% 77 fro, pop< ROY COOPER•Governor NC DEPARTMENT OF KODYH.KINSLEY•Secretary 11 - • �, HEALTH AND � J HUMAN SERVICES HELEN WOLSTENHOLME•Interim Deputy Secretary for Health •o�, °�f 6 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: Y 2-1 ZZ by p P Dote 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.): Avian Woods LLC c/o Cole Gaither Mailing address: 5835 Walnut Grove Ln City:Hickory State: NC Zip:28602 Telephone number: 843-530-8901 E-mail Address: cagaither@me.com 2. Licensed Soil Scientist(LSS)name:Caroline 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):_0 Harper Lee Dr.Newton Lot 1 of 372011667084 County Name:Catawba 6. Type of facility: ® Place of residence No.Bedrooms: 4 No.Occupants:2 ❑ Place of business Basis for flow calculation: ❑ Place of public assembly Basis for flow calculation: NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH LOCATION:5605 Six Forks Road,Raleigh,NC 27609 MAILING ADDRESS:1642 Mail Service Center,Raleigh,NC 27699-1642 www.ncdhhs.gov • TEL:919-707-5874 • FAX:919-845-3972 AN EQUAL OPPORTUNITY I AFFIRMATIVE ACTION EMPLOYER Megen McBride From: Caroline Edwards <cjedwards234@gmail.com> Sent: Tuesday, May 23, 2023 4:13 PM To: Megen McBride Subject: Re:Avian Woods Megen, Doing fine,thanks, hope all is well with you. I appreciate this information and the question. I had thought that the Covid permits with NOI expired, glad to know they do not. I would prefer that each new owner get their own permit through the county. If they/you wish to use my covid permit information to assist with that; i.e. the site plan and soils data, that is fine. Also we can be hired to do an IP/CA for each lot owner and use their new site plan. They may contract with us directly; I am best reached by email. Thank you very much and let me know any questions. Best regards, Caroline J. Edwards NC Licensed Soil Scientist#1220 NC 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. Cjedwards234@gmail.com. On Mon, May 22, 2023 at 3:44 PM Megen McBride <MMcBride@catawbacountync.gov> wrote: Hi Caroline—hope you're doing well. 1 Just wanted to clarify how you wanted to proceed with the 10 lots you did COVID permits for in Avian Woods. COVID permits where an NOI was approved, do not have an expiration date. (COVID submittals where an NOI was not approved expired 12/31/22) Also, approved COVID permits represent the equivalent of an IP and AC... so they are good for both subdivision and installation. I doubled checked with the state on what to do when property tied to an approved COVID permit is sold. They said it was up to the LSS as to whether they wanted the COVID permit to transfer to the new owner. Let me know if you want the 10 COVID permits for the lots in Avian Woods to transfer to the new owners, or if you want the new owners to get county permits. Transferring your COVID permit to a new owner would require, at a minimum, that the new owner wanted the same number of bedrooms, same house footprint, and same house dimensions as what you originally permitted. Thank you, Megen Megen McBride, REHS Environmental Health Administrator 25 Government Drive, Newton, NC 28658 (828) 465-8268 office (828) 465-8276 fax https://ww w.catawbacountync.gov/county-services/environmental-health/ cat awba county 2 COVID-19 Permit Option Common Form LHD Reference: 130-6 ~2 A,9 `i7 26 77 7. Factors that would affect the wastewater load: NONE 8. Type and located of proposed wastewater system: Illg Rear of home 9. Design wastewater flow: 480 gpd Design wastewater strength: ®domestic ❑high strength ❑industrial process(For industrial process wastewater,a Professional Engineer licensed in accordance with G.S.89C shall design the on-site wastewater system.) 10. A plat as defined in G.S.130A-334(7a)is attached: ❑Yes ® No A site plan as defined in G.S. 130A-334(13a)is attached: ®Yes ❑ No 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 ❑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 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 Examiners for Engineers and Surveyors. &A.S.) \-k• C-Scj\% Signature of Licensed Soil Scientist ` Date Owner self-submittal of NO): I, hereby submit this NOI prepared by Print Nome of Owner Print Name of Licensed PE pursuant to G.S. 130A-336.1. Signature of Owner Dote DHHS/EHS/OSWP—LSS C-19 COMMON FORM Updated April 2022 Page 2 of 6 COVID-19 Permit Option Common Form LHD Reference: Zss 06 Lo 2 —17Z677 NOTES: LIABILITY: The Department,the Department's authorized agents,or local health departments shall have no liability for wastewater systems designed,constructed,and installed pursuant to an LSS COVID-19 Permit Option(S.L.2020- 97,Section 3.19(d)and G.S.130A-336.2(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. DHNS/EHS/OSWP—LSS C-19 COMMON FORM Updated April 2022 Page 3 of 6 • COVID-19 Permit Option Common Form LHD Reference: fT P QG--ZULz ` f 2177 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 o 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,USPS,hand-delivered Print Name of Authorized Agent of the LHD Signature of Authorized Agent of the LHD Date 2 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 D '_Z via Date Email,FAX,LISPS,hand-delivered A copy of this NOI and tracking information was sent to the State on via hDate Email,FAX,LISPS,hand-delivered u ��iZL pLA,I tL - 1 4'22 Print Name of Authorized Agent of the LHD Signature of Authorized Agent of the LHD Dote DHHS/EHS/OSWP—LSS C-19 COMMON FORM Updated April 2022 Page 4 of 6 COVID-19 Permit Option Common Form LHD Reference: Zsfo 06 -Zozz 7726 77 Re-submittal of NOI with missing items included This Section Is for use by owner to submit items noted os 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#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 Deportment 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 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/EHS/OSWP—LSS C-19 COMMON FORM Updated April2022 Page 5 of 6 ass'n- aG -7011- (72G77 COVID-19 Permit Option Common Form LHD Reference: PART 3: Authorization to Operate(ATO) Except for dote 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 5. 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 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 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 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/ENS/OSWP—LSS C-19 COMMON FORM Updated April 2022 Page 6 of 6 ACORE, CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDlYYYY) 03/06/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFIC TE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Hiscox Inc. 520 Madison Avenue (ArcN o.EM): (888)202-3007 (Mc No)__ E-MAIL scox.comct hi 32nd Floor ADDRESS: conta C� New York,New York 10022 INSURER(S)AFFORDING COVERAGE NAIC I 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 TYPE OF INSURANCE ADDL SUER' POUCY EFF POUCY EXP --- LTR INSD wVD POUCY NUMBER (MM/DD/YYYYL,(MMND/YYYYL LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAL,h I O Hht I ED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ _ MED EXP(My one person) $ PERSONAL A AOV INJURY $ GEN'L AGGREGATE__ LIMIT APPLIES PER. GENERAL AGGREGATE S PE POLICY r 1 T LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident UMBRELLAUAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE A DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABIUTY YIN STATUTE ER ANYPROPRIETORIPARTNERfEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) I E.L.DISEASE-EA EMPLOYEE $ If yes,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 • •rb ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Earthwise Designs -> Soils & Land Evaluation 8/6/2021 Site and Soils Report with System Design Four-Bedroom SFH Wastewater System Lot 1, Avian Woods Phase IV Parcel ID of Subdivision Tract: 3720-1166-7084 Newton, NC Catawba County Prepared for Avian Woods LLC This report is submitted under the rule: LSS COVII)-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 found an area Provisionally Suitable for the following: 4-bedroom III g. gravelless trench,Accepted system with 25%reduction. This is not a saprolite system. A new well will be dug. Details are discussed below and in attached documents. System Specifications Initial & Repair: III g. gravelless trench, Accepted system with 25% reduction. Gravity fed. Use a d-box with an at-grade access riser such as Polylok, feeding three 100' lines. See site plan. • Soils: Group III—Clay Loam • LTAR: 0.4(See detailed soil descriptions.) • Line length required =300' o Three 100' lines. • Trench width 36" • Trench bottom: 26"on downhill side of trench. • Septic tank: 1000 gallons Other site-specific requirements and notes: 1. Heavy machinery over the drainfiield area must be avoided after installation.No structures or roads can be placed there. 2. We recommend the at-grade distribution box be inspected every 1-2 years by a private inspector. 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. 2 4. Earthwise Designs makes no guarantees regarding installation, maintenance and operations. System design may not be accurate if improper site alterations occur prior to permitting and installation. Thank you and please contact me for further information, if needed. Caroline J. Edwards NC Licensed Soil Scientist #1220 �ytio SOIL sc14 SC Professional Soil Classifier #117 `�' " J F� , T�r o tl„s,,r h- 1' NC Land Application of Bio-Solids #10006173 ` Attachments: '14 1220 Ae Soils sheet �c'`h'oRTI4 Site Plan with Legend—2 pages Phase IV Final Plat EARTHWISE DESIGNS 991 Duncan Rd Rutherfordton. NC 28139 Ciedwards234Qgmail.com 828)289-0122 cell • ,,�11 1 a o T '4, c _ c..-.N., i �� o r7v -, v E L. =.43�'- h Z.'W �i u�' p_.. aZ G L'r I Z` j 4 ` 4� a 12a0 c Sa�. or \ F.,, 7 „a3w10 1� Cao a � 11 ..,A 6 .GC > G Ea .Va E j T 'g `kiQ kkl N',,m � ^� of � o 00 1 A -` o es- I - � k a v I I }J �y I s g� sIN �M� Y U � 8 Ea w ...0 u t.ivIN ® t' -f I - r. � _ _ \i U t� ' U � � H',i Vl U�8 y y U \� C co V) n ' r> I 4 let E Q E E v. 1� °J a g3� �u b > Er V w �Ucn`'l 01 y a ter. 11'-'.% 3..g1' 7„,c11 : -'',4,.,,,.'. 0 .1''''• .....T.%,:vr,,..-.,4,..0 • . 4 1 1 t . . : ,,,i,.., , . .f...„.:,:.: _,.,,,.., .,,,,,I., .. 1 ,_ . . .. ., ,, i.1 y 0, ii..:-.11:-4'":1wif7:0144 • le.* . ,' Id o,a a c . .k.v r. iy� �Y jig �,�, p a , .:L. f — 1L' sZiJ Z e' Earthwise Designs Lot 1, Avian Woods Phase IV Cc� Soils&Land Evaluation Newton, Catawba Co.,NC Parcel 1D: 3720-1166-7084 August,2021 See written report for system details. Legend &Notes for attached Site Plan • Circled dots 1-2=pit numbers and locations. • Layout performed as indicated on 9'centers. o B=Blue flagging stakes;P=Pink;Y=yellow. o Double stakes mark the end of lines. • R=repair.Dashed lines drawn.Ample room exists. • House envelope corners marked by surveyors with wooden stakes and blue flagging. Additional locations from fixed points: PC1-PC2=property corners marked by pins and wooden stakes. Pit 1: 157' from PC1; 140'from PC2 Pit 2:232' from PC1;82' from PC2 1QSQfLS .r f(.. < k Di .z�S 1229 ./1 • • . 0) 0 �: c ig-C)�` N a ° AA„ C,C-boSS • • / (-4a / . � / -iv 2 / / � g •. oo/ R../ § 47Reltfl_x,:\ \I. oil% 1"% '.4 0-wi ti-W 1 - cl:\ — ---Nr . CI PJ?@( (NI '' o ISN, CV PO M N co co • . ,s Iiii ttaiii xi, I op allik Z9 C h 3,l0��6,v r 4a VI '4. • iy hfti o 2 ' 4f 3.1 g b NJ }} a I� @� p a F !g �' . ` FSe�'�Xfi!Tg•'s ; � 3° r Mgr gil c q t o O : , it i 4 ig 1 Well 11 ! 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