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HomeMy WebLinkAboutLSSP-06-2022-173995.tif , . .A6pR.06 -9c))- log COVID-19 Permit Option Common Form LHD Reference:-_- �y s"-6 6-2022 -I73(fry PART 3: Authorization to Operate(ATO) '311 [•1 +g bale to Except for date received,the Section below Is to be completedby the Owner. LBO USE ONLY: Initial-submittal of request for ATO received: it—i q' 1-- by_ -/�J' /JP to initials Date of Post construction Conference: /' /4- The following items are included in this submittal for an Authorization to Operate under an I.SS COVID-19 permit: 1. Signed and sealed copy of the LSS's report that Includes the information in G.S. 13DA-336.2(k) RV-es ❑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 LS5 ❑✓ Yes ❑No 5. On-site Wastewater Contractor name: William Garrison License number: 5267 Mailing address: 1936 Jamestown Rd City: Morganton State: NC Zip: 28655 Telephone number: 828-334-1537 E-mail Address: ecocleanseptic@gmail.com 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. Q Yes ❑ No 1. Attestation by the Owner for Authorization to Operate C.J I Dave Wigfield hereby attest that all items indicated above have been provided to the Print name of Owner Catawba , County LHD and the system shll meet applicable federal,State,and local laws, regulations,r es,ad orr aces. j .I.L</./1 i 2_ --- l - 2._,..>2.---7---- Signature ofOwner / 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 tHD Date ['EOMPLETE 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 t"27"23 via L L'' t% _ I��/ Date Email,FAX,LISPS,Hand-delivered 1"-✓v44..2 rkJE((,,, ./Aix- /1/ ,,.—r ,2- 1O -21 Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Dote 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 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 Ca—aw LHD Reference Number $5 f- 0 b--)0)) - 173 1q 1q 5 Permitting backlog as of date of NOI submittal(#days) 30 (A.15 Number of days to process the NOI(#days) 0 days S Number of days to process re-submitted NOI(#days or NA I "NA") 1 Facility type 3 Bedroom tou e. Domestic, High Strength or IPWW Dot Design Daily Flow 360 tied + Residential or Commercial Resicignf Q System type(per Rule.1961) Date of Post-construction conference NA Date Authorization to Operate issued (2-7.6.22 charged for LSS COVID-19 es 110.00 Is fee sufficient to cover LHD costs? yeS 1 Date LHD notified of LSS COVID-19 malfunction (( Date LHD notified of Owner complaint DHHS/EHS/OSWP—COVID-19 Appendix A Updated February 2022 Page 4 of 4 111:11111 PIEDMONT ENVIRONMENTAL ASSOCIATES , P . A . Date:_12-15-22 Project#3344 Permit# Operation Permit Checklist Site Information Address: 1311 Live Oak Lane Catawba, NC 28609 Subdivision: Lot Number 470002952449 County: Catawba PIN: Number Bedrooms: 3_Daily Design Flow: 360 gpd System Type: IIIg IQ4 Installer: Date Installed: 10-21-22 Location and Separation Distances: System meets Rule .1950 setback requirements 3' ® h I 1 Distance to Wells: 105' Distance from tank to foundation: 46' Distance from system to property lines: 38' - Supply Line:_41' 3" PVC 3'of fall Tanks:GST 1000 Septic Tank Serial Number: STB 160 Pump Tank Serial Number NA Septic Tank Date: 8-15 Septic Tank Size(gal): 1000 Pump Tank Site(gal): NA Septic Tank Condition: Good Pump Tank Condition: NA Filter: Polylok_Risers: NA System: Trench Media/Product: Infiltrator IQ4 Distribution Type: Serial Nitrification Lines:Trench width_3_'Trench Spacing_9_'Aggregate Depth 12" Line# length depth fall 1 74 19 L 2 74 19 L 3 74 19 L 4 78 19 L Soil Cover: 7" Trench Conditions: Good Stepdowns: Constructed of minimum 2 linear feet of undisturbed soil Y ( N ❑ Proper rise over stepdowns Y Z N ❑ Constructed height fully utilizes the upstream trench Y ® N ❑ Solid (non-perforated) pipe used between stepdowns YE] N ❑ Top of trench outlet,2" below supply pipe outlet invert Y ® N ❑ Operation Permit Conditions: I. Performance: System shall perform in accordance with Rule.1961. II. Monitoring: As required by Rule.1961. III. Maintenance: Ground absorption sewage treatment and disposal systems shall be checked,and the contents of the septic tank removed, periodically from all compartments,to ensure proper operation of the system.The contents shall be pumped whenever the solids level is found to be more than 1/3 of the liquid depth in any compartment. Other: Establish good grass cover as soon as possible. No traffic over drainfield Subsurface system operator required?Yes No X If yes,see attached sheet for additional operation conditions, maintenance and reporting. IV. Operation:Type Illg Homeowner to operate system V. Other: Pump tank every 3 years 1. 111 PIEDMONT ENVIRONMENTAL ASSOCIATES , P . A . December 15,2022 Project#3344 Catawba County Environmental Health Attn:Environmental Health Onsite Supervisor 100 Southwest Blvd Bldg.A Newton, NC 28658 To Whom it May Concern, I, Dave Wigfield have reviewed the material included within this package and acknowledge that I am aware of the operation procedures and maintenance of the septic system installed at 1311 Live Oak Lane in Catawba County, NC. I accept the system that has been installed on my property and that I am aware that the system was permitted through the process outlined by G. 30 -336.2(I). Signed v77c Date / Z — /5 22 STATE OF 130'1 E) L.,rc\,act COUNTY OF Xi cti c' i I On this day,11t rcr V' r r1 c kc+ personally appeared before me>>i nee; to me known to be the person(s)described in and who executed the within and foregoing instrument,and acknowledged that he/she signed the same as his/her voluntary act and deed,for the uses and purposes therein mentioned. Itness my hand and official seal hereto affixed this I S -day ofj�c e it he r , . ti C1.i UUV� c� V _(-- Notary Public in and for the State of�k.- T���� Cex. v �`�.r �� ev My commission expires r;-\4C00- ) . DINEEN V SPROUT � � 4 , Notary Public, North Carolina f S/� Iredell County ��i���: My Commission Expires March 12.2027 Layout Diagram/Site Plan - 1311 Live Oak Lane PIEDMONT ENVIRONMENTAL 216 S. Swing Rd. Suite 1 Date: 12-15-22 Ass O c l A T E 5 a A Greensboro, NC 27409 Job#3344 Client:Ace Handyman Services piedmontsoil.com County: Catawba / �, lU . , P. .T / ��, !�." / erh / ` 77 1. c County of Irecfgll GIS,Iredell --v C4 County,State of North - Carolina DOT,Esri,HERE, Garmin,GeoTechnologies, 7 V t‘ILd Inc.,NGA,USGS Legendle1K ----- -4"-- Dimension Line Supply Line e z. /// Repair Area Driveway 4 House Box / +1 -3956-sgft Q Tank Polygon / • Well '� / ltk i / 1 i , InstalllledLines / +/-2381 sgft 4 41/4 c+Alk ------ ivN �' s �/ ----- ________--------------/ _� t S:i': •i is t;�r :i:.:: `�� Isillis �G BAltF} c�� f /� ' -11 12.525 50 100 `K.,,,, '0 Q `� . m �awis .I.$ , 'Fut. s,I- d 1 1.1)//=� .?feett Car.ina t305 O" DOT, Ope,Str tM.., r oft Est,H E, ar in, afecrap , ORTH ,0- GeoTe, 77;NA.A, G ,EP ,N S,( S C ns B ea US A 1 I f DocuSign Envelope ID:3235579A-EAED-4089-9724-53CDBA9A426D Date: December 15, 2022 Installer Certification This letter certifies that William Garrison (Installer) installed a IIIg IQ4 • system, installed at 1311 Live Oak Lane Catawba, NC 28609 The system was installed in conformance with the original construction documents to meet all local and state regulations. The system was installed on October 21 , 2022 l U1'll�.as, C msou. 12/15/2022 Signe Date .4 �® DATE(MMIDOIYYYY) CERTIFICATE OF LIABILITY INSURANCE s/a/zozz 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: Valerie Leonard Younts Insurance Agency Inc PHONE IFAX 121 N Talbert Blvd _¢vc.Np.Exm 336-238-1053 NM:336-238-1054 Lexington NC 27292 ADDRESS: valerie@yountsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC INSURER A:Continental Casualty Company 2186 INSURED PIEDENV-02 INSURER B: Penn National Mutual Casualty Insurance Company 14990 Piedmont Environmental Associates, PA 216-1 S. Swing Road INSURER C:Ohio Casualty Insurance Company 24074 Greensboro NC 27409 INSURER o: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:582131835 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/1'YYY) (MM/DDIYYYY) LIMITS B X COMMERCIAL GENERAL LIABILITY BP9 0741038 6/1/2022 6/1/2023 EACH OCCURRENCE $2,000,000 CLAIMS-MADE ^ I OCCUR PREM ES�RENTED PREMISES(Ea occurrence) $300,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY I $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY X PE� [� LOC PRODUCTS-COMP/OPAGG $4,000,000 OTHER: $ B AUTOMOBILE LIABILITY AU90741038 6/1/2022 6/1/2023 COMBINED SINGLE LIMIT $1000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS x HIRED x NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident) X 19 Medical Payments I$2,000 B X UMBRELLA LIAB OCCUR UL9 0741038 6/1/2022 6/1/2023 EACH OCCURRENCE I$1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE I $1,000,000 I DEO X RETENTIONS n $ C WORKERS COMPENSATION XWO55203240 6/1/2022 6/1/2023 X STATUTE I EORH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOWPARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Professional Liability EEH288330253 6/1/2022 6/1/2023 Each Claim 2,000,000 Aggregate 2,000,000 Deductible 5,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may bo 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. "'FOR CLIENT PURPOSES ONLY""` AUTHORIZED REPRESENTATIVE / (leACJiL i Gg ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD — 702Z_ 1739y5.— �„�STAY£cG .;;; �..o.,>, as, ROY COOPER•Governor 6% � g y' NC DEPARTMENT OF KODY H.KINSLEY•Secretary HEALTH AND Ipr� ,_` HUMAN SERVICES HELEN WOLSTENHOLME• Interim Deputy Secretary for Health ., �. . 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: 6`0— 2 2 by 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.): Ace Handyman Services-Dave Wigfield Mailing address: 106 Chasetone Lane City: Mooresville State: NC Zip: 28117 Telephone number: 704-495-4818 E-mail Address: wigfielddave@gmail.com 2. Licensed Soil Scientist(LSS) name: Eric Bailey LSS License number: 1305 Mailingaddress:216 S. Swing Rd, Suite 1 City: Greensboro NC . 27409 y: State: Zip. Telephone number: 36-596-7585 E-mail Address: eric@piedmontsoil.com 3. Licensed Geologist(LG)(if applicable) name: 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): 1311 Live Oak Lane, Lot 3 Live Oak Farm County Name: Catawba 6. Type of facility: ® Place of residence No. Bedrooms: 3 No. Occupants:6 ❑ 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 DocuSign Envelope ID.EBBB9416-5DE5-4782-A72E-0F14EBO7FAAE 1 9 COVID-19 Permit Option Common Form LHD Reference: " `�� f ?��` -f73`r��s` 7. Factors that would affect the wastewater load: None 8. Type and located of proposed wastewater system: Q4 chamber. behind hnuse,3-g 9. Design wastewater flow: 360 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 1SA 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 LS5 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 Eric Bailey _hereby attest that the information required to be included with Licensed Soil Scientist(Print Nome) this Notice of Intent to Construct is accurate and complete to the best of my knowledge and that the proposed system shall meet applicable federal,State,and local laws,regulations, rules and ordinances,and that the proposed system does not require a Professional Engineer, licensed in accordance with G.S.89C, and in accordance with 1SA NCAC 18A.1938 and activities determined to be engineering as determined by the North Carolina Board of Examiners for Engineers and Surveyors. .o�o`Alt-•dby � 1 6/14/2022 - Sig/wturccgdaberaroftfiail Scientist Date Owner self-submittal of NOI: 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 Dote OHHS/EHS/OSWP—LSS C-19 COMMON FORM Updated April2022 Page 2 of 6 COVID-19 Permit Option Common Form LHD Reference: Z SfP` OG-2°Z7— r73 1 S 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. DI-MS/ENS/OW-LSS C-19 COMMON FORM Updated April 2022 Page 3 of 6 COVID-19 Permit Option Common Form LHD Reference: r! " 1 b-2 022-r73(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 Dote 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 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. Zz Copies of this signed form were sent to the LSS and the Owner on 6-1 via FAR, Date Email,FAX,USPS,hand-delivered A copy of this NOI and tracking information was sent to the State on via Date I Email,FAX,USPS,hand-delivered Ph d,r ;� ��►j- 6-0- 22 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 April 2022 Page 4 of 6 COVID-19 Permit Option Common Form LHD Reference: LSf! —06 _ 2°22—f 73g05-- Re-submittal of NOI with missing items included This Section is for use by owner to submit items noted as missing during LND Completeness Review above. Resubmittais must be accompanied by a cover letter from the LSS. LHD USE ONLY. This NOI resubmittal received: by Date initials Item#from initial NOI Resubmittal description Attestation by LSS pursuant to S.L.2020-97,Section 3.19 I, hereby attest that the information required to be included with Licensed Soil Scientist(Print Name) this Notice of Intent to Construct is accurate and complete to the best of my knowledge and that the proposed system shall meet applicable federal,State,and local laws,regulations, rules,and ordinances. Signature of Licensed Soil Scientist Date The section below is for Local Health Department use after submittal of items noted as missing above. LHD Follow-up Completeness Review of Notice of Intent to Construct This follow-up review for completeness of this Notice and Intent was conducted in accordance with G.S. 130A- 336.2(c). This NOI is determined to be: ❑ INCOMPLETE Based upon review of information 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,USPS,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 April 2022 Page 5 of 6 COVID-19 Permit Option Common Form LHD Reference: Z's 'P-6 -2022-1,3/f 5 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 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,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 Date 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