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Home My WebLink AboutIMPV-07-2022-175814.TIF catawba county public health VOLUNTARY RELINQUISHMENT OF ADMINISTRATIVE APPEAL RIGHTS Date prepared: January 4.2023 Owner(s): Riddle Custom Homes.LLC Mailing Address: PO Box 601 Denver,NC 28037 Property location/site legal description: 4172 Winona Dr. PIN: 368703415377 Imimprovement Permit(IP) 07-2022-175814 Date Issued 7/15i2022 Authorization� to Construct(AC) 08-2022-177472 Date Issued 8,10.2022 I,l -\, .Lct4tjv, (2.0A1!, ,voluntarily relinquish my rights to pursue a formal appeal through the North (print fulrname) Carolina Office of Administrative Hearings pursuant to NC General Statute i 30A-24 and 150B-23 and all other applicable provisions of Chapter 150B for the above referenced pennit(s)(which includes the IPs and ACs)in order for the authorized agent/local health department to issue the applicable permit(new IP and/or AC)for the site. I understand by completing this form that the permit(s)for a 25%reduction system Q111g1 (System description) will be revoked immediately by the authorized agent/local health department. I understand that the local health department's revocation ofa 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 IP and AC that the current IP and AC trust he revoked I understand that the local health department's revocation of an IP or CA 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 ofa 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. G � /l % Signature of Property Owner: �_�,. ) 1./_ _ I I } Date Signed:__ I k :1.1 — — - --.- - - -- - NCDHHS/DPH/EHS/OSWP Revised May 2015 catawbacountync.gov Environmental Health Catawba County Government (enter 25 Government Drive I PO Box 389 I Newton NC 28658 1818.465.8270 RIVING. BETTER. i (•A1A5KA('O171I1 (acca ISAPV•(i7.2022•I75g11 �i .t. Puhlrc IIralth Ikrartmcnl Suhdnrcinn PINE BURR �"11�� -• �`-I PmironmcntalIlcalih1)numn I'INH 368703415377 / PO Hoy 3$9,25(hr rrtimcni Dri%c.Nc,strm NI' 2X1 1()rH 1 &5 Site Address: 4172 WINONA DR,MAIDEN NC 28650 Name on Permit: RICHARD(LOGAN)'RIDDLE Property Size: Acres 1 03 Directions: S Hwy 16.Left on MI Beulah Right on Winona Lot of left Owner/Authorized Representative Acknowledgement of Permit Receipt A.l certify that I am the owner or authorized agent(owner's authorization required)representing the owner of Kr ('the property described aho%e. RLYL- As the property owner or authorized representative,I have received the above referenced / permit(s)as requested in the application for service RBPR-04-2022-40586.by the following method(s): Received in Person Facsimile'Transmittal (Return form with signature required) _J. Electronic Image Transmittal,.E-mail (Return receipt required) As the property owner or authorized representative I have reviewed and understand the specific conditions r. 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(I5A NCAC 18A.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:07/15/2022 (� ? /7 Owner'Authorized Representative Signature r c:.��?,.� �,fl�;A, Date 1-4r- 1;,4.)- J I P D n I Documentation of Permit(s)Transmittal (permit transmitted by electronic or other means) Permit transmitted by (,tune r,/irt'rsru,soling permit) Signature (it Date/Time 7 42Z Method: Fax J 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 yotPlease ttake a few momentts tto complette our custtomer service survey att http://www.surveymonkey.com/s/EHCusttomerServicce 1 opor) d lei IGggb-iL'. Ceir`-- . ^ (016':0'2 16)4 r =_„ CATAWBA COUNTY Case# IMPV-07-2022-175814 ti A .Z Public health Department Subdivision PINE BURR .< ''1 Environmental Health Division PIN# 368703415377 PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 1 &5 $� w Site Address: 4172 WINONA DR, MAIDEN NC 28650 Name on Permit: RICHARD(LOGAN)*RIDDLE Property Size: Acres 1.03 Directions: S Hwy 16, Left on Mt Beulah Right on Winona Lot of left Owner/Authorized Representative Acknowledgement of Permit Receipt I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of the property described above. As the property owner or authorized representative, I have received the above referenced permit(s)as requested in the application for service RBPR-04-2022-40586,by the following method(s): Received in Person Facsimile Transmittal(Return form with signature required) J Electronic Image Transmittal/E-mail (Return receipt required) As 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 18A.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: 07/15/2022 Owner/Authorized Representative Signature_ Date 1POnq Documentation of Permit(s)Transmittal (permit transmitted by electronic or other means) Permit transmitted by (name of person sending permit) Signature ciE Date/Time 7 )1.i f 2L- I i Method: Fax `r 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 yoiPlease ttake a few momentts tto complette our custtomer service survey aft http://www.surveymonkey.com/s/EHCusttomerService fojmiidcJkc1& rtai0. e - 6p�rout 07/26/2022 16:39 %r� CATAWBA COUNTY Case# IMPV-07-2022-175814 ,' .t. ,t Public Health Department Subdivision PINE BURR d -- '3 Environmental Health Division PIN# 368703415377 PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 1 &5 8, sr+ i Site Address: 4172 WINONA DR, MAIDEN NC 28650 Name on Permit: RICHARD(LOGAN)*RIDDLE Property Size: Acres 1.03 Directions: S Hwy 16, Left on Mt Beulah Right on Winona Lot of left Improvement Permit AN AUTHORIZATION TO CONSTRUCT MUST BE ISSUED PRIOR TO BUILDING PERMITS THIS PERMIT IS NOT FOR SEPTIC INSTALLATION Permit Category: New Septic Wastewater Flow 360 d 9.P. Type of Facility: Primary Residence Basement? No Basement Plumbing? No Bedrooms: 3 Water Supply: Private Well Maximum Occupants: 6 INITIAL SYSTEM SPECIFICATIONS Proposed Wastewater System: 25%REDUCTION System Classification: IIIG-OTHER NON-CONY TRENCH SYSTEMS REPAIR SYSTEM SPECIFICATIONS Repair System Required? Required Proposed Wastewater System: 25%REDUCTION System Classification: IIIB-SYSTEM W/SINGLE EFFLUENT PUMP Pump Required Permit Conditions: *Do not cut,drive,fill, or grade over septic or repair areas. *This is an improvement permit only and is not intended for septic installation purposes. *Initial system will be a saprolite system, but the repair will not. *Authorization to Construct can't be issued until lots 1 and 5 are combined. Landscaping or other site alterations that potentially divert groundwater or surface water toward the septic system, or prevent proper drainage away from the septic system, including the direction of gutter flows or foundation drains,is not approved,and may result in failure to approve the initial system installation,or the suspension/revocation of existing permits. The issuance of this permit by the Health Department does not guarantee the issuance of other permits. It is the responsibility of the applicant /property owner to insure that all Catawba County Planning/Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocation if the site plan,plat or the intended use changes,or if site conditions are altered. The Improvement Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina'Laws and Rules for Sewage Treatment and Disposal Systems' (I5A NCAC I 8A.1900). Neither Catawba County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily for any given period of time. Any permit issued for a conventional system may be used for an accepted system without Environmental Health authorization or permit modification.Please notify Environmental Health of this change prior to system installation. i --../ 07/15/2022 Authorized State Agent Permit Issuance Date 7/15/2027 Permit Expiration Date No grading or construction activity is allowed in areas designated for system and repair without approval of the Health Department. clipermit 07/26/2022 16:39