HomeMy WebLinkAboutAUTH-09-2022-181174.TIF +� 1
• Catawba county
public health
VOLUNTARY RELINQUISHMENT OF ADMINISTRATIVE APPEAL RIGHTS
Date prepared: NOVEMBER 14TH 2024 -
Owner(s): LEMON BOWL RENOVATIONS
Mailing Address: 16115 CHILTEN LN
HUNTERSVILLE,NC 28078
Property location/site Iegal description: 3639 MT BEULAH RD
PIN: SHERRILLS FORD.NC 28673
Authorization to Construct(AC) AUTH 09-2022-181174 Date Issued: 9/27/2022
NGY l�(��-} e�m mat�h ,voluntarily relinquish my rights to pursue a formal appeal through the North
still name)
Carolina Office of Administrative Hearings pursuant to NC General Statute I30A 24 and 150B 23 and all other applicable
provisions of Chapter 150B for the above referenced permit in order for the authorized agent/local health department to issue the
applicable permit(new AC)for the site. I understand by completing this form that the permit for a
IIIG 25%REDUCTION
(System description)
will be revoked immediately by the authorized agent/local health department.
I understand that the Iocal 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 Pror-P-dnre Act. InnriPrstand that in order for
the localheaith department to issue another AC that the current AC must be revoked. I understand that the local health department's
revocation ofan AC 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 atihe 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.
Iunderstand that I am not required to relinquish my appeal rights but that this is an option available tome so I.do not have to wait 30
days for the revocation ofthe pe /it to take effect.
�V11
Signature ofProperty Owner. ;Lt U. '1' o-rill eeito ikdiert
� 1
Date Signed: ii iq' 211
NCDHHS/DPH/EHS/05WP Revised May 2015
catawbacountync.gov
Environmental Health
Catawba County Government Center
25 Government Drive I PO Box 389 I Newton NC 28658 1 828.465.8270
MAKING. LIVING. BETTER.
\C.• CA\TAIVBA COUNTY r
•
,.1.� Public Health Department Sutxlivisiun
log • Environmental Health Division PINK 368702869549
PO Box 189,25 Government Drive,Newton,NC I8658 LOTH 3
Sit.Addr.ss: 3639 MT BEULAH RD,SHERRILLS FORD NC 28673
Nam.on Permit: 'LEMON BOWL RENOVATIONS LLC
Property Six.: Acres 1.06
Directions: Right off of Little Mountain Rd onto Mt Beulah Rd.4th lot on right after Lineberger Rd.
Owner/Authorized Representative Acknowledgement of Permit Receipt
)(1Wil I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
(the property described above.
X1'(\L.As the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service RBPR-07-2022-41545,by the following method(s):
Received in Person
_ Facsimile Transmittal(Return form with signature required)
f Electronic Image Transmittal/E-mail (Return receipt required)
Pi Asthe 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(I5A 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:09/27/2022
•
Owner/Authorized Representative Signature "Aka-6,-,AAI
p� —
7 Date � 1 �2-�
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
SignatureqC Date/Time 9130/))
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 yosPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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