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Home My WebLink AboutWELL-06-2022-174625.TIF G) catawba county public health VOLUNTARY RELINQUISHMENT OF ADMINISTRATIVE APPEAL RIGHTS Date prepared: 10/12/_2023 — - Owner(s): Adam Dymora Mailing Address: 913 Edmond St NW _ Valdese,NC 28690 -- Property location/site legal description: 8765 Jacob Fork River Rd,Vale _____ PIN: 266801485389__ Well Permit WELL-06.2022-174625 Date Issued: 6/27/2022 I. _cr1 � YY1(yR ,voluntarily relinquish my rights to pursue a formal appeal through the North (print full n me) Carolina Office of Administrative Hearings pursuant to NC General Statute 130A-24 and 150E-23 and all other applicable provisions of Chapter 150E for the above referenced permit(s)in order for the authorized agent/local health department to issue the applicable permit(Well permit)for the site. I understand by completing this form that the permit(s)for a NPyv Well (well permit type) will be revoked immediately by the authorized agent/local health department. I understand that the local health department's revocation of a permit can be appealed to the North Carolina Office of Administrative Hearings within 30 days of the revocation pursuant to the North Carolina Administrative Procedure Act. I understand that in order for the local health department to issue another Well Permit that the current Well Permit must be revoked. I understand that the local health department's revocation of the Well Permit is not effective until 30 days from the revocation or,if the revocation is appealed,at the time that the Office of Administrative Hearings issues a final decision. I understand that by signing this form and relinquishing my right to appeal the permit revocation at the Office of Administrative Hearings that the local health department's permit revocation will become effective immediately. I understand and agree that the revocation of a permit that takes effect immediately is in my best interest. I understand that by signing this form that I agree that I do not want to appeal the permit revocation. I understand that I am not required to relinquish my appeal rights but that this is an option available to me so I do not have to wait 30 days for the revocation of the permit to take effect. Signature of Property Owner: I i — ;./'(- / L Date Signed: 10 I ?j J �3 ' / NCDHHS/DPH/EHS/OSWP Revised May 2015 catawbacountync.gov Environmental Health (ocwbc County Government (enlei 25 Government Drive I PO Box 389 I Newton N( 28658 I 828.465 8210 MAKING. LIVING. BETTER. 1 (4 Catawba county public health October 12, 2023 Adam Dymora 913 Edmond St NW Valdese, NC 28690 Subject: Notice of Intent to REVOKE the Well Permit for 8765 Jacob Fork River Rd,Vale PIN 266801485389 Catawba County Permit: WELL-06-2022-174625 Dear Mr. Dymora: The Environmental Health Division of Catawba County Public Health intends to revoke your Well Permit 30 days from the date of this notice. If the permit is revoked,you must apply for a new Well Permit and meet the requirements of the current laws and rules necessary to obtain a new Well Permit. You have a right to an informal review of this decision. You may request an informal review by the environmental health supervisor at the local health department. You may also request an informal review by the NC Department of Health and Human Services Regional Specialist.A request for informal review must be made in writing to the local health department. You also have a right to a formal appeal of this decision. To pursue a formal appeal, you must file a petition for a contested case hearing with the Office of Administrative Hearings, 1711 New Hope Rd, Raleigh, NC 27609. You may write the Office of Administrative Hearings, call the office at (984) 236- 1850 or get a copy of the petition form from the OAH web site at http://www.oah.nc.gov. The petition for a contested case hearing must be filed in accordance with the provision of North Carolina General Statutes 130A-24 and 150E-23 and all other applicable provisions of Chapter 150B. North Carolina General Statute 130A-335 (g) provides that your hearing would be held in the county where your property is located. If you wish to pursue a formal appeal, you must file the petition form with the Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. The date of this letter is 10/12/2023. Meeting the 30-day deadline is critical to your formal appeal. catawbacountync.gov Environmental Health Catawba County Government Center 25 Government Drive I PO Box 389 I Newton NC 28658 1828.465.8270 MAKING. LIVING. BETTER. If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by law (NC General Statute 150E-23) to serve a copy of your petition on the Office of General Counsel, NC Department of Health and Human Services, 2001 Mail Service Center, Raleigh, NC 27699- 2001. Respectfully, ife—i$Inte Pt,;k;4J Blake Perkins, REHSI Environmental Health Specialist Catawba County Public Health CATAWBA COUNTY ITia iPublic Health Department Subdivision ..-� Environmental Health Division PINK 266801485389 PO Box 389,25 Government Drive,Newton,NC 28658 LOT# Site Address: 8765 JACOB FORK RIVER RD,VALE NC 28168 Name on Permit: ROBERT LAWHON Property Size: Acres 34.05 Directions: Turn R on Old Shelby Rd to Jacobs Fork, Land has black gate half mile down road on left Owner/Authorized Representative Acknowledgement of Permit Receipt certify that I am the owner or authorized agent(owner's authorization required)representing the owner of the property described above. /`cettlie the property owner or authorized representative, I have received the above referenced permit(s)as requested in the application for service RBPR-01-2022-39943, by the following method(s): Received in Person Facsimile Transmittal(Return form with signature required) jElectronic Image Transmittal/E-mail (Return receipt required) the property owner or authorized representative I have reviewed and understand the specific conditions ?(, of the permit issued, and further understand that all applicable regulatory requirements specified under the North Carolina Laws and Rules for Sewage Treatment and Disposal Systems(15A NCAC I8A.1900), and/or Well Construction Standards (15A NCAC 2C .0100), shall apply to the issuance of this permit and the construction of the wastewater system and/or water supply well permitted. Permit Issue Date:06/27/2022 Owner/Authorized Representative Signature Date ( 11,° 22 • Documentation of Permit(s)Transmittal (permit transmitted by electronic or other means) Permit transmitted by (name of person sending permit) ic)Signature E, Date/Time CY ))l)� Method: Fax i Email US Mail Other Owner's request to send by the above indicated method of transmittal in lieu of signature We wantt tto hear from yooPlease ttake a few momentts tto complette our custtomer service survey att http://www,surveymonkey.com/s/EHCusttomerService aIc w� ai,,'ik„,;y vi re-ni e1y6d1111ii 06/270.022 14.16 rf Catawba County Environmental Health 1 RdPR or- io2Z - 3 y3 1 Iyn�v-O - Zl2 j �,YYg u41—o?- - Z�7z- ��bYy5 •8765 . 1 okeo _ 077 -011Co75 1.1 Lid IS 3a Pro P 36R 3or • / PIM' 7-6 i1°�L fZ'U.I fpp . r• IDD /q•tfat 7d J Parcel: 266801485389, 8765 JACOB FORK l 1 in=80ft RIVER RD VALE, 28168 This map/report product wee prepared from the Catawba County,NC oeoepatlal Information Services. Catawba County has made substantial efforts to ensure the accuracy of location and labeling Information contained on this map or data on this report.Catawba County promotes and recommends the Independent verification of any data containod on lhle maplroport product by the usor.The County of Catawba,Its employees,agents,and personnel,disclaim,and shall not be held liable for any and all damages,loss or liability,whether direct,Indirect or consequential which arises or may arise from this map/report product or the use thereof by any person or entity. Copyright 2021 Catawba County NC 06/27/2022