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Home My WebLink AboutIMPV-07-2022-176448.tif fia i catawba county public health VOLUNTARY RELINQUISHMENT OF ADMINISTRATIVE APPEAL RIGHTS Date prepared: _J0/12l2023 Owner(s): ___ -_Assam Dymora __ Mailing Address:______913 Edmond St NW ______ Valdese,NC 28690 Property location/site legal description:_ 8765 Jacob Fork River Rd,Vale _ PIN: 266801485389 Improvement Permit(IP) IMPV-07-2022.176448 Date Issued _7/26/2022 _ Authorization(to Construct(AC) AUTH-07-2022-176449 Date Issued 7/26/2022 I, ABM 1�fY10111t voluntarily relinquish my rights to pursue a formal appeal through the North (print full name) Carolina Office of Administrative Hearings pursuant to NC General Statute 130A-24 and 1508-23 and all other applicable provisions of Chapter 150E for the above referenced permit(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 Illg—25%Reduction (System description) 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 IP and AC that the current IP and AC must be 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 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 rev oca tion of th�peermit to take effect. Signature of Property Owner: L — t P ) 11 / Date Signed: 101 13 1 z3 NCDHHS/DPH/EHS/OSWP Revised May 2015 catawbacountync.gov Environmental Health (.:it;wI (uun'y Guvern.nunl (elites 25 Guveinrient Dive PO box 389 I Newton li( 28658 1823.465 82/0 MAKING. LIVING. BETTER. (a catawba county public health October 12, 2023 Adam Dymora 913 Edmond St NW Valdese, NC 28690 Subject: Notice of Intent to REVOKE the Improvement Permit and Authorization to Construct for 8765 Jacob Fork River Rd,Vale PIN 266801485389 Catawba County Permits IMPV-07-2022-176448 and AUTH-07-2022-176449 Dear Mr Dymora: The Environmental Health Division of Catawba County Public Health intends to revoke your Improvement Permit and Authorization to Construct 30 days from the date of this notice. If the permits are revoked, you must apply for a new Improvement Permit and Authorization to Construct(IP/AC) and meet the requirements of the current laws and rules necessary to obtain a new IP/AC. 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 Soil Scientist.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 Church 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 150B-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. 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 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. If you file a petition for a contested case hearing with the Office of Administrative Hearings,you are required by law (NC General Statute 150B-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, ice_alnee Pe:k,ns Blake Perkins, REHSI Environmental Health Specialist Catawba County Public Health e CATAWBA COUNTY .',' Public Health Ikpartment Subdivision ,� Environmental Health Divisiontyrilr PIN# 266801485389 PO Box 389,25 Government Drive.Newton,NC 28658 LOD/ 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 )( -- _-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-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) 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:07/26/2022 Owner/Autht ized 2epresentativc Signature � (� 7 f Date V ! Documentation of Permit(s)Transmittal (permit transmitted by electronic or other means) Permit transmitted by _ _ (name gfperson sending permit) Signature , ...... DatC/TimC_ D Ill Method: Fax 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 youPlease ttake a few momentts tto complette our custtomer service survey aft http://www.surveymonkey.com/s/EHCusttomerService a 1,4“,h,,,x?hilk.tiivyOtt.. Ern J � 0.1,;unn 07272022 10 23 „II! • CATAWBA COUNTY Case# IMPV-07-2022-176448 r .j.111 ,y Public Health Department Subdivision "1 Environmental Health Division PIN# 266801485389 1.1".J 'I(....... PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 1 2 w 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 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 g.p.d Type of Facility: Primary Residence-New House 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: 50%REDUCTION HORIZONTAL System Classification: IIIE-PPBPS GRAVITY DOSED SYSTEM Permit Conditions: See AC 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' (15A NCAC 18A.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. 3/Pifite if}/'€ ‘ 07/26/2022 Authorized Slate Agent Permit Issuance Date 7/26/2027 Permit Expiration Date No grading or construction activity is allowed in areas designated for system and repair without approval of the Health Department. I,pernut 07/27/2022 10:24 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 OE PART\iFNT OF III Al T11 AND III'MAN SF.RVIC FS Sheet I ,„,f I DIVISION OF Pt-111 IC ill;A1 T11.FN\'1RO\MFNTAI HEALTH SUCTION PROPERTY II)O. '4 PbQ/?S41 ON-S111"%AMR PROTLCT1ON BRANCH COI INTY:..CG,}AWbA SOIL/SITE EVALUATION for ON SITE WASTEWATER SYSTEM (C.mpkte all fields in full) OWNER: J� �rJ GWI}e/j __ APPLICATION DATE ADDRESS: 3412 - NC / DATE EVALUATED:----- PROPOSED FACILITY: N✓ • PR SE�Qj.DESIGN yOW(.1949): 3 bp 6PD PROPERTY SIZE: LOCATION OF SITE:, GLab ThI fi'i ! a� S[C/1 A.( f '/b3' PROPERTY RECORDED: ____ \\:\TER SUPPLY: _- Private = Public � \�'c1l 2 Spring P Other f EV:ALU.ATION METHOD: . Aucer Boring _VPit :.:Cut TYPE OF WASTEWATER: P'I Sewage I 1 Industrial Process I ?Mired i f . r R SOIL MORPHOLOGY OTHER e j (.1941) PROFILE FACTORS 1 .1.140 t 1..\\DSCAPI: IlOR1iON - - POSITION' DEPTH PROFILE. .1942 Sl OPE".. (INA CLASS SOIL .1941 .1941 .19J3 .1956 .1944 SOH. STRI CTl RE/ CONSISTENCE/ WETNESS/ SOIL SAPRO RESTR &LTAR TE\Tl RE MINERAU.OG\ COLOR DEPTH CLASS IIORIZ L s 0-3 , e i¢el( Fr, SSf, 5Xe, , f 3 -' ' C sex Ff, 5s,s,,sae tit l o f is- qS Ct dC w a Fr/ sc,s,,SfX9 3 1. 5 0-Li , c 4LK f ss,s?, c, ,, ps Li-is , ,c sir Fri 5S,Sri S6 yg �� !S- Yg ,u 6t Pat rriSS�,�,sc. 8 ' 0. L S ,0-ye , C sex ,.sfs'sock, PS 3b-5�/ . C SQk . Ss, 91 t 10 O. 3 1,,c ° 2)45) C fig 4 ffi Sri-fesvit . es 16-S5 ( SiK ,fir{SIi ►, SE , S 4 + 1tocK 0115 N ti :�11.%\ 1\111.1 SVS11\( RI 1`.iR Nl'S11\I (VIER FACll)RS(.I44ti).-.._ �7 _ _ ' SOT CLASSIFICATION 1.1 o4Sl: 1L . _. ....� ,;�, L . > J (., ii" sp f Iced OTHER(S1 PRESENT. , 14 . M N Snc I :.I: 0. 3 D. 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