HomeMy WebLinkAboutAUTH-08-2022-177472.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
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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.
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`4;1s CATAWBA COUNTY' ,,,,,,, .._ _
4"11111.1 vc..(..vci 1,. Public Ilcalth lkpnrtmcnI Subdivision PINE BURR
r : tF Environmental Health Division PINII 368703415377
PO Box 389,25 Gmemment Drive,Newton,NC 2811511 LOT# 1 &5
Sits Address: 4172 WINONA DR,MAIDEN NC 28650
Neme 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
Lcertify that I am the owner or authorized agent(owner's authorization required)representing the owner of
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the property described above.
4-,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)
Electronic Image Transmittal/E-mail (Return receipt required)
`v"--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:08/10/2022
Owner/Authorized Representative Signature K� — fit 4__ f/e
Date — 1S .G'•)-`
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
C
Signature t
__.________ Date/Time 7 iisizI ,
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 youPlease hake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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