Loading...
HomeMy WebLinkAboutEOP-10-2022-182405.tif State of NC EOP LHD Reference: EO 1 - 10-2o22 l V 230 PART 3: Authorization to Operate(ATO) Except for date received,the Section below is to be completed by the Owner or by the PE designated to act as their legal representative for the EOP.LHD USE ONLY: Initial submittal of request for ATO received: (1-r by 6-21- Z3 i Dote Initials Date of Post-construction Conference: VI-Al'' The following items are included in this submittal for an Authorization to Operate under an EOP: 1. Signed and sealed copy of the Engineer's report that includes: \A. Signed and sealed evaluation of soil conditions and site features ElYes ElNo 1/b. Drawings,specifications,plans ®Yes ❑ No -/c. Reports on special inspections and final inspection 0 Yes ❑ No mod. Management Program manual ❑Yes 0 No —_ e. On-site Wastewater Contractor's signed statement ❑Yes 0 No ✓f. Signed and sealed statement pursuant to 15A NCAC 18A.1938(h) 0 Yes ❑ No `'2. Fee (as applicable) ❑Yes X❑ No l./3. Notarized letter documenting Owner's acceptance of the system from the PE ❑X Yes ❑ No Attestation by the Owner or the PE for Authorization to Operate Daniel Shabeldeen hereby attest that all items indicated above have been provided to the Print name of Owner or Professional Engineer Caldwell County LHD and the system shall meet applicable federal,State,and local laws, regulations, rules and ordinances in accordance with G.S. 130A-336-.1(e)(6), /Signal rre of Owner or Professional Engineer Dote This section for LIID Use Only. LHD Review of required information for the ATO ❑ INCOMPLETE Based upon review of information submitted by the Owner or PE in the Section above,the following items are missing from the information required for an Authorization to Operate for an EOP: Copies of this signed form were sent to the design PE and the Owner on via Date Email,FAX,LISPS,Hand-delivered Pr'ntname of authorized Agent of the LHD Signature of authorized Agent of the LHD Dote COMPLETE Based upon review of information submitted by the Owner or PE in the Section above,this Authorization to Operate is hereby issued in accordance with G.S. 130A-336.1(m). t#A copy of this complete NOI/ATO with tracking inf mation was sent he to on via . tin M �} rat Date Email,FAX,U$P Non slivered I�1na 11t authorized l/rJ aV 11/ZJ Print n of Agent of the LHD Signal e authorized Agent o the LHD D e ISSUANCE OF CERTIFICATE OF OCCUPANCY: Once the LHD determines completeness based upon the PE submission,the owner may apply to the local permitting agency for permanent electrical service to a residence,place of business or place of public assembly pursuant to G.S.130A-339. Page 6 of 6 DHHS/ENS/OSWPB—COMMON FORM Effective June 1,2018 SHABELDEEN ENGINEERING, PA 3145 TATE BLVD. SE• BOXA • HICKORY, NC • 28602 PHONE: (828) 320-7252 CIVIL/WATER/SEWER/ENVIRONMENTAL FAX: (828) 394-4126 CONSTRUCTION MANAGEMENT dan@shabeldeen-engineering.corn June 27, 2023 Mr. Robbie Phelps Environmental Health Supervisor Catawba County Environmental Health 25 Government Drive Newton, NC 28658 SUBJECT: 6276 Lynchburg Rd Septic System EOP Certification Hickory, Falls, NC PIN: 3735-16-94-1712 Mr. Phelps: In accordance with the state of NC EOP, I am submitting the attached Authorization to Operate (ATO) form and required documentation. Accompanying this letter are the following items: 1. Authorization to Operate Form 2. Evaluation of soil conditions prepared by Mr. Joe Lynn, LSS 3. Record drawing and specifications signed and sealed (submitted on August 24, 2022) 4. Professional engineer's certification (submitted on August 24, 2022) 5. Owner's approval of the on-site wastewater system and request for post-construction meeting be waived 6. Owner's acceptance of the system and statement of property ownership. I appreciate the County's assistance on the project. Please do not hesitate to contact me if you have any questions. gpve CL' CAip._ Ill{�lo o .Ssro, � - 9r Y '` Daniel Shabeldeen, P.E. SEAL 029232 z ; 6/27/2023 _Fl SH As�ro ,� SHABELDEEN ENGINEERING LOT Phelps Lynchburg Eng Certitication.docx �, Ethics • Integrity • Engineering MVE LLC JOHN KAISER Soil/Site Report Owner: MW@ John Kaiser Parcel# 373516941624 An evaluation of the soil properties on the aforementioned property has been conducted, as part of the due diligence process to determine if this property could support a subsurface wastewater dispersal (septic) system. The property was evaluated in accordance with North Carolina Statutes for waste disposal ("Laws and Rules for Sewage Treatment and Disposal Systems",The purpose of the investigation was to determine suitability for an On-Site Wastewater (septic) System to serve a residence. Site suitability is based on but not limited to topography, soil characteristics, soil wetness, soil depth, restrictive horizons, and available space. This report lists the findings, conclusions and recommendations for the property. (828) 310-0089, E-mail at joe.lynnoswps@yahoo.com. 50I1 SC Joe Lynn LSS 2 N O LUOy Q,0 , Vet GP Site suitability is based on but not limited to topography, soil characteristics, soil wetness, soil depth, restrictive horizons, and available space. This investigation was accomplished by traversing the property (County GIS map) and observing land-forms (slope, drainage patterns, gullies, past uses, etc.) as well as soil characteristics (depth, structure, texture, seasonal wetness, etc.). OWNER/APPLICANT: MW2 John Kaiser LOCATION: 6276 Lynchburg Rd. COUNTY: Catawba TYPE OF FACILITY: Residence DESIGN UNIT: 240 gallons per day WATER SUPPLY: Well AREA/USE: .43 acres TOPOGRAPHY: 5 to 30% LANDSCAPE POSITION: Linear slope SITE LIMITATIONS: Wells, Lake Hickory, Duke Energy Right of Way DATES OF EVALUATION: 08/27/2021, 02/21, 03/28, 05/24, 07/22/2022 EVALUATED BY: Joe Lynn ONSITE WASTEWATER SYSTEM PROPOSAL Description Initial System Repair System Available Space Suitable Suitable System Type PPBPS horizontal T&J panels _TS-II drip Site LTAR .25 0.15 System Size 160 feet 800 feet # Trenches 4 16 Length of Trenches varies 50 foot Trench Depth 20 inches lower wall 6 inches Distribution Method Pressure Manifold Septic Tank 1,000 gallon Pump Tank 1,000 gallons The house can not have a foundation drain • SITE PREPARATION No grading is to be done. The area for the initial system and the repair cannot be graded. Remove the existing house very carefully, do not damage the soil area in front of the house. SYSTEM INSTALLATION The initial system, must be located as shown in the attachments and the Improvement Permit and Authorization to Construct. The septic tank and pump tank should be installed as shallow as possible. The system must meet setbacks: 50-100' from wells (depending on soil type and space), 50' from streams and ponds, 10' to 25' to storm water diversions (gullies, ditches, etc.)10' property lines,15' from top of embankments greater than two feet in depth and if a retaining wall with a drain is used the setback distance must be 25 feet, 15 from pools, etc. The systems must be installed when the soil is not wet. Consult Environmental Health about soil wetness and system installation. A description of each pit/boring is attached and the attached maps display the approximate locations of the pits/borings and noteworthy features. DISCLAIMER The findings in this report represent my professional opinion about soil and site conditions based upon the information available to me during the evaluation. Variability in the soils could result in conditions that are unpredictable and different than what I found. I am not responsible for errors made due to unclear, unknown, or misrepresented property lines. I am not responsible for difficulties caused by the location of overlooked critical features (such as wells, utility lines, water lines, streams, septic systems, buildings, etc.) on this or neighboring property. There are other circumstances beyond the scope of this report that could create problem that might deny the use of the property as desired. Some of these include: zoning laws, excessive grading, and misallocations of houses, drives, property lines, wells, and utilities. Buried utilities and culvert runoff should not cross drainfields, septic tanks, or repair areas. SOIL/SITE EVALUATION FOR ON-SITE WASTEWATER SYSTEM Owner/Applicant: MW2 LLC John Kaiser Date Evaluated: 02/21, 03/28/2022 Address/Phone #: County/ PIN #: Catawba 373516941712 Facility: Residence Design Flow: 240 gpd Property Size: .43 acres Location/Road: 6276 Lynchburg Rd. Subdivision/Lot#: _ Water Supply Public Private Well Xx Community well Evaluation Method Auger Boring X Pit X Cut Type of Wastewater Sewage X IPWW Mixed Profile Landscape Horizon Texture Structure Consistency Saprolite Soil Soil Profile Position & Depth Mineralogy Wetness depth classification Slope in. Color &LTAR 1 LS 0-10/11 L GR FR 10/11- C SBK/ABK Fl 39 PS .275 39 2 LS 5-6% 0-6 L GR FR 6-13 CL SBK Fl _ 13-35 C SBK/ABK Fl _ 35 US .25 rock saprolite reclassify 3 LS 8-10% 0-8 L , GR FR 8-36 C SBK/ABK FR 36 PS .25 rock saprolite 4 LS 10% 0-6 L GR FR US auger 6-23 C SBK/ABK Fl PRESENT USE: OTHER FACTORS: Wells, lake, old house EVALUATED BY: Joe Lynn OTHER(S) PRESENT: COMMENTS: Pit 2 can be reclassified and used, pits 2 & 3 had some rock and saprolite, old house on the lot shared septic system with adjoining lot, neighboring lots have wells, this lot will have a well, duke energy power line right of way. Auger boring is PS for a TS-II drip. . . ' 'Landscape Texture Structure Mineralogy 'Mineralogy Position consistency consistency ,.-- Ridge Sand Crumb Moist Moist R S 1 CR 1 Shoulder slope Loamy sand Granular Slightly expansive Expansive S LS GR Nose slope Sandy loam I Block like loose Very firm N SL VF --, . — Head slope Loam Subangular Very friable Extremely firm H L SBK VFR EF Foot slope Silt loam Angular Friable FS 1 SIL I ABK FR H i - Flood plain 1Silt 'Platy Firm FP SI PL Fl Drainage way Sandy clay loam Prismatic D SCL PR -r- ,- Terrace Silty clay loam Absence I Wet Wet T .SICL A Debris slope Clay loam Slightly sticky Very sticky DS CL SS VS Sandy clay ,Sticky SC S 1 Concave slope Silty clay Non plastic Very plastic CC SIC NP VP 1 Convex slope Clay Slightly plastic CV C SP Plastic -----I P _____ SHABELDEEN ENGINEERING, PA 3145 TATE BLVD. SE • BOXA • HICKORY, NC • 28602 PHONE: (828) 320-7252 CIVIUWATER/SEWER/ENVIRONMENTAL FAX: (828) 394-4126 I CONSTRUCTION MANAGEMENT dan©shabeldeen-engineering.corn June 27, 2023 Mr. Robbie Phelps Catawba County Environmental Health P.O. Box 389 Newton, NC 28658 SUBJECT: 6276 Lynchburg Rd —Septic System Engineer's Certification Hickory, NC 28601 PIN: 3735-16-64-1712 Mr. Phelps: I, Daniel Shabeldeen, P.E., as a duly registered professional engineer in the State of North Carolina, provided periodic observation of the construction, start-up, and testing of the septic system at the above referenced site and found that the system was generally constructed in accordance with approved plans and record drawing dated June 10, 2023. Signature: ,r'''�e� F�N ssro c4Ro. 2: o Registration No.: 029232 SEAL P z Date: June 27, 2023 0ti ��crr,EF- oi+���� �FC S H Ae�`'/p if SHABELDEEN `� ENGINEERING Lynchburg Eng Certification I.docx Ethics •Integrity • Engineering • June 23, 2023 Mr. John Kiser 7478 Botanica Pkwy Sarasota, FL 28601 Mr. Robbie Phelps Environmental Health Supervisor Catawba County Environmental Health 25 Government Dr. Newton, NC 28658 SUBJECT: 6276 Lynchburg Rd Septic System EOP Waiver Hickory, NC PIN: 3735-16-94-1712 Mr. Phelps: As the owner of the referenced property, I approve of the on-site wastewater system and request that the post-construction on-site meeting be waived. The system is a Type III PPBPS system serving a single-family residence at 240 GPD with a minimum system review frequency of five (5) years. I appreciate your cooperation on this project. Si/"rely, / sal John Kiser Ltr Lynchburg Waiver.docx • June 23, 2023 Mr. John Kiser 7478 Botanical Pkwy Sarasota, FL Via email: blwworking@aol.com SUBJECT: Septic System Acceptance Statement 6276 Lynchburg Rd. - Hickory, NC PIN: 3735-16-94-1712 Mr. Phelps: As the owner of the referenced property, I accept the on-site wastewater system from the engineer. In accordance with Rule 15A NCAC 18A.1938(j), the entire wastewater sewage system is on property that I own. No legal agreements, easements, encroachments, or multi- party agreements are required. Si ely, John Kiser STATE OF NORTH CAROLINA COUNTY OF Cato, b Ct I,V,imberN k .Cr o 4O'd, a Notary Public, certify that 0O n M_ K k 5 err personally appeared before me this day and acknowledged that he/she is the 'owner of +he prepe.-kt , and that in such capacity and being authorized to do so, executed the forgoing on behalf of the corporation/company. m h d eal s this day of Jul y 20 2. Notary Public C [SEAL) y,„commission expires: I / I 4:3/ 2 02G, o wg A C O Ja'`" Ltr Lynchburg Acceptance.docx June 27, 2023 Mr. Robbie Phelps Catawba County Environmental Health P.O. Box 389 Newton, NC 28658 SUBJECT: 6276 Lynchburg Rd — Septic System Installer's Certification Hickory, NC 28601 PIN: 3735-16-64-1712 Mr. Phelps: Max's Digging Service installed the septic system at the above address generally as shown on the record drawing dated June 10, 2023. Sincerely, W SHABELDEEN f- ENGINEERING Ltr Phelps Lynchburg Installcr.docx Elk Ethics • Integrity • Engineering j,z7t L nckbur Ad )-1!cKor , E6P- IO-2o22- Ig2-tO5. UK- oR-zo2z-y.zo3- �'mAT atu,4 ROY COOPER •Governor �o� ,o.n„ '1'Q+w �`"�t Z *?1) NC DEPARTMENT OF KODY H. KINSLEY•Secretary 6, Ae �: HEALTH AND L_1�'Ii a�` HUMAN SERVICES HELEN WOLSTENHOLME • Interim Deputy Secretary for Health OA a is MARK T. BENTON•Assistant Secretary for Public Health Division of Public Health COMMON FORM FOR ENGINEERED OPTION PERMIT See Instructions for Use in Appendix A Except for"Date received",this Section to be completed by the Professional Engineer licensed in accordance with G.S.89C LHD USE ONLY: Initial submittal of this NOI received: f- -1 L - 2.'1- by .11Z1J REC� Dote Initials PART 1: Notice of Intent to Construct(NOI)-Please check all that apply A U G 2 2 2022 ®Single System or ❑Multiple Systems AND Environmental Health X❑New ❑ Expansion ❑ Relocation of all or part of the Existing System ❑ Relocation of Repair Area ❑ Repair-LHD Permit Number ❑ Repair-EOP/LSS COVID 19/AOWE Permit Number 1. Facility Owner's name:(Owner,Company Name,Utility, Partnership,Individual,etc.): MW2 LLC Mailing address: 7478 Botanica Pkwy City: Sarasota State: NC Zip: 28601 Telephone number: 941.993.4748 E-mail Address: blwworking@aol.com 2. Professional Engineer(PE)name: Daniel Shabeldeen License number: 029232 Mailing address: 3145 Tate Blvd.SE City: Hickory —State: NC Zip: 28602 Telephone number: 828.320.7252 E-mail Address: dan@shabeldeen-engineering.com 3. Licensed Soil Scientist(LSS)name: Joseph Lynn License number: 1089 Mailing address: 6768 George Hildebran School Rd City: Hickory State: NC Zip: 28602 Telephone number: 828.310.0089 E-mail Address: joe.lynnoswps@yahoo.com 4. Licensed Geologist(LG)(if applicable)name: N/A License number: Mailing address: City: State: Zip: Telephone number: E-mail Address: 5. On-Site Wastewater Contractor name: Max's Digging Service License number: 1127 Mailing address: 1972 Adam St. — City: Conover State: NC Zip:28613 Telephone number: 828.596.6040 E-mail Address:millerbj57@gmail.com 6. Proof of Errors and Omissions or other appropriate liability insurance for the following persons is attached that includes the name of the insurer,name of the insured and the effective dates of coverage: [] PE El LSS ❑ LG 0 On-site Wastewater Contractor NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH LOCATION:5605 Six Forks Road, Raleigh, NC 27609 MAILING ADDRESS:1642 Mail Service Center,Raleigh, NC 27699-1642 www.ncdhhs.gov • TEL:919-707-5874 • FAX 919.845-3972 AN EQUAL OPPORTUNITY I AFFIRMATIVE ACTION EMPLOYER Engineer Option Permit Common Font.' LHD Reference: E0I- 1() -LV�. ��✓,Iv1J 7. Property location(physical address,tax parcel identification number or subdivision lot,block number of the property to be permitted): 6276 Lynchburg Rd;Hickory,NC 28601 County Name: Catawba 8. Type of facility: X❑ Place of residence No. Bedrooms: 2 No.Occupants: ❑ Place of business Basis for flow calculation: ❑ Place of public assembly Basis for flow calculation: 9. Factors that would affect the wastewater load: None 10. Type and location of proposed wastewater system: PPBPS Horizontal;front yard 11. Design wastewater flow: 240 gpd(For flow>3,000 gpd and industrial process,duplicate plans shall be sent to the State.) Design wastewater strength: ®domestic ❑high strength ❑industrial process 12. A plat as defined in G.S. 130A-334(7a)is attached: ®Yes ❑ No 13. Location of proposed or existing wells(drinking water,irrigation,geothermal,groundwater monitoring, sampling,etc.)and any potable and non-potable water conveyance lines is indicated on attached plans and complies with 1SA NCAC 18A.1950: X❑Yes ❑No This is a saprolite system. ❑Yes 17] No 14. Evaluation(s)of soil conditions and site features in accordance with G.S. 130A-335(al)signed and sealed by a LSS is attached: ®Yes ❑No 15. Evaluation of geologic and hydrogeologic conditions signed and sealed by a LG is attached ❑Yes ❑X NA 16. Proposed landscape,site,drainage,or soil modifications are attached: X❑Yes ❑NA Attestation by Professional Engineer licensed in North Carolina pursuant to G.S.89C I, Daniel Shabeldeen hereby attest that the information required to be included with Registered Professional Engineer(Print Name) this Notice of Intent to Construct is accurate and complete to the best of my knowledge and that the proposed system shall meet applicable federal,State,and local laws,regulations, rules,and ordinances in accordance with G.S. 130A-336-.1(e)(6). gnature of Licensed Professional Engineer ate DHHS/ENS/OSWP—EOP COMMON FORM Updated April 2022 Page 2 of 6 Engineer Option Permit Common Form` LHD Reference: W1 - (b 2022-1 YCi This section is for Owner use to either designate PE as their legal representative or to self-submit the N01. Designation of Registered Professional Engineer as legal representative of Owner for this Notice of Intent: John Kiser hereby designate Daniel Shabeldeen Print Name of Owner Print Name of Registered Professional Engineer as my legal representative for purposes of this Notice of Intent pursuant to G.S. 130A-336.1. )fei.A.,_. 11 . - .2 2, Signature of Owner Date Owner self-submittal of NO!: t, hereby submit this NOI prepared by Print Name of Owner Print Name of Licensed PE pursuant to G.S. 130A-336.1. Signature of Owner Date NOTES: LIABILITY: The Department, the Department's authorized agents,or local health departments shall have no liability for wastewater systems designed,constructed,and installed pursuant to an Engineer Option Permit(G.S. 130A- 336.1(f)] RIGHT OF ENTRY: The submittal of this Notice of Intent to Construct grants right of entry to the Local Health Department and the State to the referenced property. ISSUANCE OF BUILDING PERMIT: Once the LHD deems that the Notice of Intent to Construct is complete via signature in the section below, the owner may apply to the local permitting agency for a permit for electrical, plumbing,heating,air conditioning or other construction, location,or relocation activity under any provision of general or special law pursuant to G.S. 130A-338. DHHS/EHS/OSWP—EOP COMMON FORM Updated April 2022 Page 3 of 6 • Engineer Option Permit Common Form LHD Reference:-ELE`% w -- P - (LI This section for Local Health Department use only. PART 2: LHD Completeness Review of the Notice of intent to Construct "(c)Completeness Review for Notice of Intent to Construct.-The local health department shall determine whether a notice of intent to construct,as required pursuant subsection(b)of this section,is complete within 15 business days after the local health department receives the notice of intent to construct. A determination of completeness means that the notice of intent to construct includes all of the required components. if the local health department determines that the notice of intent to construct is incomplete,the department shall notify the owner or the professional engineer of the components needed to complete the notice. The owner or professional engineer may submit additional information to the deportment to cure the deficiencies in the notice. The local health department shall make a final determination as to whether the notice of intent to construct is complete within 10 business days after the department receives the additional information from the owner or professional engineer. If the department fails to act within any time period set out in this subsection,the owner or professional engineer may treat the failure to act as a determination of completeness." The review for completeness of this Notice of intent was conducted in accordance with G.S. 130A-336.1(c). This NOI is determined to be: ❑ INCOMPLETE(If box is checked, Information in this section is required.) Based upon review of information submitted in Part 1,the following items are missing: _ Copies of this form listing missing items were sent to the design PE and the Owner on Date via _with directions to re-submit missing items using Page 5 of this form. Email,FAX USPS,hand-delivered Print Name of Authorized Agent of the LHD Signature of Authorized Agent of the LHD Dote E1' COMPLETE(If box is checked,information in this section is required.) Based upon review of information submitted in Part 1 of this form,this NOI is deemed COMPLETE. Copies of this signed form were sent to the design PE and the Owner on}" b4� (2 via ''"u i I . Date Email,FAX,USPS,hand-delivered A copy of this NOI and tracking information was sent to the State on via Date Email,FAX,USPS,hand-delivered (L,1, 4_. f hut1 )J— - (-. /9Gv,- �5— ZZ Print Name of Authorized Agent ofthe LHD Signature of Authorized Agent of the LHD Date DHHS/EHS/OSWP-EDP COMMON FORM Updated April 2022 Page 4 of 6 • • Engineer Option Permit Common Form LHD Reference: Ea• lV 2l/C-(,- 1%,f V`7 Re-submittal of NOI with missing items included This Section is for use by the owner or PE to submit Items noted as missing during LHD Completeness Review above. Resubmittals must be accompanied by a cover letter from the PE. LHD USE ONLY: This NOI resubmittal received: _ by— Dote Initials Item#from initial NOI Resubmittal description Attestation by Professional Engineer licensed in North Carolina pursuant to G.S.89C hereby attest that the information re-submitted for this Notice of Licensed Professional Engineer(Print Name) Intent to Construct is accurate and complete to the best of my knowledge and that the proposed system shall meet applicable federal,State,and local laws,regulations,rules and ordinances in accordance with G.S. 130A-336- .1(e)(6). Signature of Licensed Professional Engineer Date The section below Is for Local Health Department use after submittal of items noted as missing above. LHD Follow-up Completeness Review of Notice of intent to Construct This follow-up review for completeness of this Notice and Intent was conducted in accordance with G.S. 130A- 336.1(c). This NOI is determined to be: ❑ INCOMPLETE Based upon review of information submitted in the RESUBMITTAL above,this Notice of Intent remains INCOMPETE because the following items from Part 1 of this form remain missing: - • Copies of this signed form were sent to the design PE and the Owner on via Date Email,FAX,USPS,Hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Dote ❑ COMPLETE Based upon review of information submitted in the RESUBMITTAL above in addition to information provided in Part 1 of this form,this NOI is deemed complete. Copies of this signed form were sent to the PE and the Owner on via Date Email,FAX,USPS,Hand-delivered A complete copy of this form with tracking information was sent to the State: via Date Email,FAX,USPS,hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Date DHHS/EHS/OSWP-EOP COMMON FORM Updated April 2022 Page 5 of 6 MVE LLC JOHN KAISER Soil/Site Report Owner: MW@ John Kaiser Parcel# 373516941624 An evaluation of the soil properties on the aforementioned property has been conducted, as part of the due diligence process to determine if this property could support a subsurface wastewater dispersal (septic) system. The property was evaluated in accordance with North Carolina Statutes for waste disposal ("Laws and Rules for Sewage Treatment and Disposal Systems",The purpose of the investigation was to determine suitability for an On-Site Wastewater (septic) System to serve a residence. Site suitability is based on but not limited to topography, soil characteristics, soil wetness, soil depth, restrictive horizons, and available space. This report lists the findings, conclusions and recommendations for the property. (828) 310-0089, E-mail at joe.lynnoswps@yahoo.com. O - � O SOIL SC Joe Lynn LSS 4" Ne �rA 9�F 1.voy Q.0 • Site suitability is based on but not limited to topography, soil characteristics, soil wetness, soil depth, restrictive horizons, and available space. This investigation was accomplished by traversing the property (County GIS map) and observing land-forms (slope, drainage patterns, gullies, past uses, etc.) as well as soil characteristics (depth, structure, texture, seasonal wetness, etc.). OWNER/APPLICANT: MW2 John Kaiser LOCATION: 6276 Lynchburg Rd. COUNTY: Catawba TYPE OF FACILITY: Residence DESIGN UNIT: 240 gallons per day WATER SUPPLY: Well AREA/USE: .43 acres TOPOGRAPHY: 5 to 30% LANDSCAPE POSITION: Linear slope SITE LIMITATIONS: Wells, Lake Hickory, Duke Energy Right of Way DATES OF EVALUATION: 08/27/2021 , 02/21, 03/28, 05/24, 07/22/2022 EVALUATED BY: Joe Lynn ONSITE WASTEWATER SYSTEM PROPOSAL Description Initial System Repair System Available Space Suitable Suitable System Type PPBPS horizontal T&J panels TS-II drip Site LTAR .25 0.15 System Size 160 feet 800 feet #Trenches 4 16 Length of Trenches varies 50 foot Trench Depth 20 inches lower wall 6 inches Distribution Method Pressure Manifold Septic Tank 1,000 gallon _ Pump Tank 1,000 gallons The house can not have a foundation drain 1 SITE PREPARATION No grading is to be done. The area for the initial system and the repair cannot be graded. Remove the existing house very carefully, do not damage the soil area in front of the house. SYSTEM INSTALLATION The initial system, must be located as shown in the attachments and the Improvement Permit and Authorization to Construct. The septic tank and pump tank should be installed as shallow as possible. The system must meet setbacks: 50-100' from wells (depending on soil type and space), 50' from streams and ponds, 10' to 25' to storm water diversions (gullies, ditches, etc.)10' property lines,15' from top of embankments greater than two feet in depth and if a retaining wall with a drain is used the setback distance must be 25 feet, 15 from pools, etc. The systems must be installed when the soil is not wet. Consult Environmental Health about soil wetness and system installation. A description of each pit/boring is attached and the attached maps display the approximate locations of the pits/borings and noteworthy features. DISCLAIMER The findings in this report represent my professional opinion about soil and site conditions based upon the information available to me during the evaluation. Variability in the soils could result in conditions that are unpredictable and different than what 1 found. I am not responsible for errors made due to unclear, unknown, or misrepresented property lines. I am not responsible for difficulties caused by the location of overlooked critical features (such as wells, utility lines, water lines, streams, septic systems, buildings, etc.) on this or neighboring property. There are other circumstances beyond the scope of this report that could create problem that might deny the use of the property as desired. Some of these include: zoning laws, excessive grading, and misallocations of houses, drives, property lines, wells, and utilities. Buried utilities and culvert runoff should not cross drainfields, septic tanks, or repair areas. SOIL/SITE EVALUATION FOR ON-SITE WASTEWATER SYSTEM _ Owner/Applicant: MW2 LLC John Kaiser Date Evaluated: 02/21, 03/28/2022 Address/Phone #: County/ PIN #: Catawba 373516941712 Facility: Residence Design Flow: 240 gpd Property Size: .43 acres Location/Road: 6276 Lynchburg Rd. Subdivision/Lot #: Water Supply Public Private Well Xx Community well Evaluation Method Auger Boring X Pit X Cut _ Type of Wastewater Sewage X IPWW Mixed Profile Landscape Horizon Texture Structure Consistency Saprolite Soil Soil Profile Position & Depth Mineralogy Wetness depth classification Slope in. Color &LTAR _ 1 LS 0-10/11 L GR FR 10/11- C SBK/ABK Fl 39 PS .275 39 2 LS 5-6% 0-6 L GR FR 6-13 CL SBK Fl _ 13-35 C SBK/ABK Fl 35 US .25 rock saprolite reclassify 3 LS 8-10% 0-8 L GR FR 8-36 C SBK/ABK FR 36 PS .25 _ rock saprolite 4 LS 10% 0-6 L GR FR US auger _ 6-23 C SBK/ABK Fl PRESENT USE: OTHER FACTORS: Wells, lake, old house EVALUATED BY: Joe Lynn OTHER(S) PRESENT: COMMENTS: Pit 2 can be reclassified and used, pits 2 & 3 had some rock and saprolite, old house on the lot shared septic system with adjoining lot, neighboring lots have wells, this lot will have a well, duke energy power line right of way. Auger boring is PS for a TS-II drip. Landscape Texture Structure Mineralogy Mineralogy Position consistency consistency Ridge Sand Crumb Moist 'Moist R S CR Shoulder slope Loamy sand Granular Slightly expansive Expansive S LS .GR Nose slope Sandy loam Block like loose Very firm N SL VF Head slope Loam Subangular Very friable Extremely firm H L SBK VFR EF Foot slope Silt loam Angular Friable FS SIL ABK FR [Flood plain Silt Platy Firm FP SI PL FI Drainage way Sandy clay loam Prismatic D SCL PR i Terrace Silty clay loam Absence Wet Wet T SICL A Debris slope Clay loam Slightly sticky Very sticky DS CL SS VS _—J 1 Sandy clay Sticky SC S Concave slope •Silty clay Non plastic Very plastic CC SIC NP ;VP Convex slope Clay Slightly plastic 1CV C SP j Plastic p SHABELDEEN ENGINEERING, PA 3145 TATE BLVD. SE • BOX A • HICKORY, NC • 28602 PHONE: (828) 320-7252 CIVIUWATER/SEWER/ENVIRONMENTAL FAX: (828) 394-4126 CONSTRUCTION MANAGEMENT dan@shabeldeen-engineering.com June 27, 2023 Mr. Robbie Phelps Catawba County Environmental Health P.O. Box 389 Newton, NC 28658 SUBJECT: 6276 Lynchburg Rd — Septic System Engineer's Certification Hickory, NC 28601 PIN: 3735-16-64-1712 Mr. Phelps: I, Daniel Shabeldeen, P.E., as a duly registered professional engineer in the State of North Carolina, provided periodic observation of the construction, start-up, and testing of the septic system at the above referenced site and found that the system was generally constructed in accordance with approved plans and record drawing dated June 10, 2023. Signature: — I1�N SARo p oF�_sio Registration No.: 029232 �k''' SEALhk 029232 Date: June 27, 2023 0'1/,t4"G,NOe o��itl _FC SHtOC/jrl SHABELDEEN ENGINEERING Lynchburg Fng Certification I.dock Ethics •Integrity •Engineering June 23, 2023 Mr. John Kiser 7478 Botanica Pkwy Sarasota, FL 28601 Mr. Robbie Phelps Environmental Health Supervisor Catawba County Environmental Health 25 Government Dr. Newton, NC 28658 SUBJECT: 6276 Lynchburg Rd Septic System EOP Waiver Hickory, NC PIN: 3735-16-94-1712 Mr. Phelps: As the owner of the referenced property, I approve of the on-site wastewater system and request that the post-construction on-site meeting be waived. The system is a Type III PPBPS system serving a single-family residence at 240 GPD with a minimum system review frequency of five (5) years. I appreciate your cooperation on this project. Si77:.rely, lj 1n John Kiser l.,tr I nchhurg Waivcr.docx June 23, 2023 Mr. John Kiser 7478 Botanical Pkwy Sarasota, FL Via email: blwworking@aol.com SUBJECT: Septic System Acceptance Statement 6276 Lynchburg Rd. - Hickory, NC PIN: 3735-16-94-1712 Mr. Phelps: As the owner of the referenced property, I accept the on-site wastewater system from the engineer. In accordance with Rule 15A NCAC 18A.1938(j), the entire wastewater sewage system is on property that I own. No legal agreements, easements, encroachments, or multi- party agreements are required. 7 Si , ely, John Kiser STATE OF NORTH CAROLINA COUNTY OF taw a Q I, V\irniscrki 14- •Cr oiw-forci, a Notary Public, certify that t1'in M K 13 ,r• personally appeared before me this day and acknowledged that he/she is the 0 Wfl&r^ of -the pfcpe fit' and that in such capacity and being authorized to do so, executed the forgoing on behalf of the corporation/company. _ W' s m hadnfiffi44 �r. this TI day of J Ul V 20 2. Notary Public [SEAL � commission expires: I / I ql 2 D�. ''' K. C Hq L'La,, , AN% �O011. �ARY 90 S.Z ''�9TgwgA Cp ��`'`. Ltr Lynchburg Acceptance.docx SHABELDEEN ENGINEERING, PA 3145 TATE BLVD. SE• BOX A • HICKORY, NC • 28602 PHONE: (828) 320-7252 CIVIL/WATER/SEWER/ENVIRONMENTAL FAX: (828) 394-4126 CONSTRUCTION MANAGEMENT dan@shabeldeen-engineering.com June 27, 2023 Mr. Robbie Phelps Environmental Health Supervisor Catawba County Environmental Health 25 Government Drive Newton, NC 28658 SUBJECT: 6276 Lynchburg Rd Septic System EOP Certification Hickory, Falls, NC PIN: 3735-16-94-1712 Mr. Phelps: In accordance with the state of NC EOP, I am submitting the attached Authorization to Operate (ATO)form and required documentation. Accompanying this letter are the following items: 1. Authorization to Operate Form 2. Evaluation of soil conditions prepared by Mr. Joe Lynn, LSS 3. Record drawing and specifications signed and sealed (submitted on August 24, 2022) 4. Professional engineer's certification (submitted on August 24, 2022) 5. Owner's approval of the on-site wastewater system and request for post-construction meeting be waived 6. Owner's acceptance of the system and statement of property ownership. I appreciate the County's assistance on the project. Please do not hesitate to contact me if you have any questions. rl,.\, CARp le`o &E.ssiati2 Daniel Shabeldeen, P.E. SEAL 6/27/2023 029232 z 4,1 NEE v0��t FC S ff,74SHABELDEEN ENGINEERING !Ayr Phelps Lynchburg Eng C'crtilication.docx Ethics • Integrity • Engineering EOP Tracking information The LHD completes this form for each NOI/ATO submitted to their offices. The LHD updates this information and re- sends it throughout the process as appropriate. The Department will use this data to draft required legislative reports on implementation of the EOP. Tracking information for Engineered Option Permits(Required) County LHD Reference Number Permitting backlog as of date of NOI submittal(#days) Number of days to process the NOI(#days) Number of days to process re-submitted NOI(#days or "NA") Facility type Domestic,High Strength or IPWW Design Daily Flow Residential or Commercial System type(per Rule.1961) Date of Post-construction conference Date Authorization to Operate issued Fee charged for EOP Is fee sufficient to cover LHD costs? Date LHD notified of EOP malfunction Date LHD notified of Owner complaint DHHS/EHS/05WP—EOP Appendix A Updated February 2022Page 4 of 4 SHABELDEEN ENGINEERING, PA 3145 TATE BLVD. SE• BOX A • HICKORY, NC • 28602 PHONE: (828) 320-7252 CIVIL/WATER/SEWER/ENVIRONMENTAL FAX: (828) 394-4126 CONSTRUCTION MANAGEMENT dan@shabeldeen-engineering.corn August 22, 2022 Mr. Dean Evans Catawba County Environmental Health P.O. Box 389 Newton, NC 28658 SUBJECT: Engineered Option Permit Submittal 6276 Lynchburg Rd.; Hickory PIN: 3735-16-94-1712 Mr. Evans: On behalf of the MW2, LLC (Owner), Shabeldeen Engineering, PA (SEPA) is submitting the following items for an Engineered Option Permit. 1. Notice of Intent (NO)) 2. Soils Evaluation by Mr. Joe Lynn, LSS (dated January 13, 2022) 3. Septic System Plan (dated January 28, 2022) 4. Proof of insurance LSS, PE, and contractor Project Description The Owner is in the process of constructing a new house on the referenced lot. The parcel is 0.43 acre. There is an existing structure built in the 1930's that will be demolished. The new structure will be a two (2) bedroom slab-on-grade structure sitting in the same footprint. The daily flow will be 240 gpd. The dosing rate will be Mr. Joe Lynn, LSS conducted the soils evaluation. Based on the evaluation, the septic system will be a Type III consisting of the following major components: 1. 1,000-gal. pre-cast concrete septic tank 2. 1,000-gal. pre-cast concrete pump tank with Zoeller N98 series pump 3. Dosing rate will be 22 gpm at 18' TDH 4. Pressure manifold with four (4) 1/2" Sch40 PVC taps 5. Four (4) rows of horizontal T&J panels each 40 LF in length. As shown on the plans, the drainlines will be 8-feet on center and offset 10 feet from the north property line. The drainlines and septic tank will be offset 5 feet from the structure. The repair area will be located between the structure and the lake buffer consisting of a TS-II drip system. Please do not hesitate to contact me if you have any questions. Sincerely, tt c'' ESSi 4'� '• ;4`. QQ° °",�' Daniel Shabeldeen, P.E. OP9232 z'� August 22, 2022 t. f3VGtrtEEP ��t}1 SF4P' lid �� SHABELDEEN �,� ENGINEERING t tr hu rt,rinrt Ethics • Integrity •Engineering W U ro f �"� ¢ a�i O I'= �� c y m 3 ; I a�v n b O p ( V� Y i cNN �'" ^ C '�I j W v J U 00 0• S •cr co 5 zl o 2 0 C WOO Z J W g Q a t y c, ii Q V 2 0 Q \J Q pp • z W O v W ! a C f>a ,z y C W 0) 4 0-Z - U ; N LAKE HICKORY N C'� n 'T a.z . Ni Cc 0 UQ U N Fla- I-Lj Nu, Q �UO 87.82'--T TI ao p o o Sze tj 07°��' 2'E iIE i0 Q:0'PIPE O r ,C~ tliJl q w / In $ O 0 U�v iNO �Ux / a o --;�`x 4n "aa 3s,1/ 'a 3 g V 2 N QT w a/�� o C V3 M ^Ltind c �20 Y tl(�yCa�0-3 N)-N - ��mo0d1 yy�5,, aaU� a�`NZ U x W���Cx 7. -cWD oc) o q ao� al4a •a 3G p� 4 C i N �j N o - M W.w,_, 4 2pp V FT^. 0 eE §$ a Lia ti ! m o O .., Q x LLI PpgcK .....4, 3 W m 3 F- °: 4 L�Rp' 4, 8 .. . .... by s, S'Lg m i R ., FRAME hm W n �ja;z e \ i M C• c0 � 5{OR� .. s o6 N J aQ, F W W Re ..) Wo h U2U Zy.2 Np *I J 1 llJ N co QQO"' §%2 W W 0 3 0 'n 0: $ u) $= � v i K W C1= N `OPIYE m2,Z0§h nb 1 eu~t` 0 Z =y62zt3c W oC L 'tom I 1 �N. '1' 1 0\ 1 1 N If),J r 4, 0 +f l . z �Woy�o �. U W U Wcz4ca a )-cY � z CO N 8 d S 03°f4'42'E 64.70'— . CO ^' ZO 60' R/W d ilE'O QOd'P;vf C<�'W� • W �— N 06°44'14"W 64.98' otd: HI.NC,C � 1 W�V�CO o W LYNCHBURG ROAD cc J a. - --U o o0 a 8 OM2 3c � a do'0330 w0 0 N u IflH1�ON ma. w-z N df m zh H L.Q4�yVS~ 34o Ocpa026 Z -:N I•i R MVE LLC JOHN KAISER Soil/Site Report Owner: MW@ John Kaiser Parcel# 373516941624 An evaluation of the soil properties on the aforementioned property has been conducted, as part of the due diligence process to determine if this property could support a subsurface wastewater dispersal (septic) system. The property was evaluated in accordance with North Carolina Statutes for waste disposal (`Laws and Rules for Sewage Treatment and Disposal Systems",The purpose of the investigation was to determine suitability for an On-Site Wastewater (septic) System to serve a residence. Site suitability is based on but not limited to topography, soil characteristics, soil wetness, soil depth, restrictive horizons, and available space. This report lists the findings, conclusions and recommendations for the property. (828) 310-0089, E-mail at joe.lynnoswps@yahoo.com. SOIL SC Joe Lynn LSS w /c, tiAr V N ti Site suitability is based on but not limited to topography, soil characteristics, soil wetness, soil depth, restrictive horizons, and available space. This investigation was accomplished by traversing the property (County GIS map) and observing land-forms (slope, drainage patterns, gullies, past uses, etc.) as well as soil characteristics (depth. structure, texture, seasonal wetness, etc.). OWNER/APPLICANT: MW2 John Kaiser LOCATION: 6276 Lynchburg Rd. COUNTY: Catawba TYPE OF FACILITY: Residence DESIGN UNIT: 240 gallons per day WATER SUPPLY: Well AREA/USE: .43 acres TOPOGRAPHY: 5 to 30% LANDSCAPE POSITION: Linear slope SITE LIMITATIONS: Wells, Lake Hickory, Duke Energy Right of Way DATES OF EVALUATION: 08/27/2021 , 02/21 , 03/28, 05/24, 07/22/2022 EVALUATED BY: Joe Lynn ONSITE WASTEWATER SYSTEM PROPOSAL Description Initial System I Repair System Available Space _ Suitable l Suitable System T •e PPBPS horizontal T&J panels TS-II drip Site LTAR .25 0.15 System Size 160 feet 800 feet # Trenches 4 16 Length of Trenches varies 50 foot Trench Depth 20 inches lower wall 6 inches Distribution Method _ Pressure Manifold FThp tic Tank 1000 gallon mp Tank 1 ,000 gallonse house can not have a foundation drain SITE PREPARATION No grading is to be done. The area for the initial system and the repair cannot be graded. Remove the existing house very carefully, do not damage the soil area in front of the house. SYSTEM INSTALLATION The initial system, must be located as shown in the attachments and the Improvement Permit and Authorization to Construct. The septic tank and pump tank should be installed as shallow as possible. The system must meet setbacks: 50-100' from wells (depending on soil type and space), 50' from streams and ponds, 10' to 25' to storm water diversions (gullies, ditches, etc.)10' property lines,15' from top of embankments greater than two feet in depth and if a retaining wall with a drain is used the setback distance must be 25 feet, 15 from pools, etc. The systems must be installed when the soil is not wet. Consult Environmental Health about soil wetness and system installation. A description of each pit/boring is attached and the attached maps display the approximate locations of the pits/borings and noteworthy features. DISCLAIMER The findings in this report represent my professional opinion about soil and site conditions based upon the information available to me during the evaluation. Variability in the soils could result in conditions that are unpredictable and different than what I found. SOIL/SITE EVALUATION FOR ON-SITE WASTEWATER SYSTEM Owner/Applicant: MW2 LLC John Kaiser Date Evaluated: 02/21, 03/28/2022 Address/Phone #: County/ PIN #: Catawba 373516941712 Facility: Residence Design Flow: 240 gpd Property Size: .43 acres Location/Road: 6276 Lynchburg Rd. Subdivision/Lot #: Water Supply Public Private Well Xx Community well Evaluation Method Auger Boring X Pit X Cut Type of Wastewater Sewage X IPWW Mixed _ Profile Landscape Horizon Texture Structure Consistency Saprolite Soil Soil Profile Position & Depth Mineralogy Wetness depth classification Slope in. Color & LTAR 1 LS 0-10/11 L GR FR 10/11- C SBK/ABK Fl 39 PS .275 39 2 LS 5-6% 0-6 L GR FR 6-13 CL SBK Fl 13-35 C SBK/ABK Fl 35 US .25 rock saprolite reclassify 3 LS 8-10% 0-8 L GR FR 8-36 C SBK/ABK FR 36 PS .25 rock saprolite 4 LS 10% 0-6 L GR FR US auger 6-23 C SBK/ABK Fl PRESENT USE: OTHER FACTORS: Wells, lake, old house EVALUATED BY: Joe Lynn OTHER(S) PRESENT: COMMENTS: Pit 2 can be reclassified and used, pits 2 & 3 had some rock and saprolite, old house on the lot shared septic system with adjoining lot, neighboring lots have wells, this lot will have a well, duke energy power line right of way. Auger boring is PS for a TS-II drip. Landscape Texture Structure Mineralogy Mineralogy Position consistency consistency Ridge Sand Crumb Moist Moist R S CR Shoulder slope Loamy sand Granular Slightly expansive Expansive S LS GR Nose slope Sandy loam 'Block like loose Very firm N SL VF Head slope Loam Subangular Very friable Extremely firm H L SBK VFR EF Foot slope Silt loam Angular Friable FS SIL ABK FR Flood plain Silt Platy Firm FP SI PL Fl Drainage way Sandy clay loam Prismatic D SCL PR Terrace Silty clay loam Absence Wet Wet T SICL A Debris slope Clay loam Slightly sticky Very sticky DS CL SS VS Sandy clay Sticky SC S Concave slope Silty clay Non plastic Very plastic CC SIC NP VP Convex slope Clay Slightly plastic CV C SP Plastic P I am not responsible for errors made due to unclear, unknown, or misrepresented property lines. I am not responsible for difficulties caused by the location of overlooked critical features (such as wells, utility lines, water lines, streams, septic systems, buildings, etc.) on this or neighboring property. There are other circumstances beyond the scope of this report that could create problem that might deny the use of the property as desired. Some of these include: zoning laws, excessive grading, and misallocations of houses, drives, property lines, wells, and utilities. Buried utilities and culvert runoff should not cross drainfields, septic tanks, or repair areas. • Acco D CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) `„/ 01/28/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. — If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Jarice Adams NAME: Insurance Management Consultants,Inc. PHONE (704)799-1600 I FAX (704)799-2955 (AICIL°,Ext): IA/C,No): PO.Box 2290 -__ EADDRESS: Janice@ilncipls.com INSURER(S)AFFORDING COVERAGE NAIC 0 Davidson NC: 28036 INSURER A: RLI Insurance Company 13056 INSURED INSURER B: Shabeldeen Engineering,PA INSURER C 2905 9th St Place NE INSURER D: INSURER E: Hickory NC 28601 INSURER F: COVERAGES CERTIFICATE NUMBER: 22-23 GLAUTO PL 21-22 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ••• i,r:- POLICY EFF POLICY EXP LTR TYPE OF INSURANCE I s mg POLICY NUMBER (MM/DD/YYYY)1MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OC:CURREN E $ DAMAGE 10 RENTED 1,000,000 C_AIMS-MADE X OCCUR PREMISES(Ea occxrence) S MED EXP(Any one person) $ 10.000 A PSB0005085 01i0212022 01102/2023 PERSONA._BADVINJ:URY S 1.000,000 — GEN'LAGGREGATE LIMIT APPLIES PER. _GENERAL AGGREGATE $ 2,000,000 X POL CY PRO- 2,000,000 JECT LOC: PRODUCTS-COM°/OPAGG $ OTHER $ AUTOMOBILE LIABILITY ' OMBINED SINGLE LIMIT s 1,000,000 (Ea acudent) X ANY AUTO BODILY INJURY(Per person) $ A J OWNED SCHEDULED PSA0002663 01/08/2022 01/08/2023 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY (Per accident) Uninsured motorist $ 1,000,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE: AGGREGATE $ CEO RETENTIONS S WORKERS COMPENSATION PER OTH- X STATUTE ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTN%P/ ECUTIY'E YIN1.000.000 A OFFICERIMEMBEREXCLUDE / �� NIA PSW0004406 10/03/2021 "0l03/2022 E.L.EACHACCIDENT S (Mandatory In NH) E L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes.describe under DESCRIPTION OF OPERATIONS below _ _ E.L.DISEASE-POLIC'LIMIT $ 1•000,000 Per Claim $1,000,000 Professional Liability A ROP0045726 01/02/2022 01/02/2023 Aggregate $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE , R; / ice; I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD 03) ACo 1) CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDUWW) `..-/ 2/1/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsetnent(s). PRODUCER CONTACT Stephanie Horan NAME: P Wade Associates, LLC iA/O NE No.Eat): (704)1392-9297 (AC,No) (?oatede-oae5Y P.O. Box 1209 E-MAIL shoran@wadeict.com ADDRESS: _ 212 S Main Street _-_ INSURERIS)AFFORDING COVERAGE _ NAIC a !_ Davidson _ NC 28036 INSURER A:Auto-Owners Insurance Company 18988 -_ INSURED INSURER B:Markel Insurance Company Joe D Lynn Jr. INSURER C: 6768 George Hildebran School Road INSURER D: INSURER E: Hickory NC 28602 INSURER F COVERAGES CERTIFICATE NUMBER:21-22 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQU'REMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INBR ADDL SUER - -- POLICY EFF POLICY EXP -- LTR TYPE OF INSURANCE INS) WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY1, LIMITS -X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000 DAMAGE`0 RENTED A CLAIMS-MADE X OCCUR PREMISES :Ea occurrence) 300,000ence) $ -_� 35515975 9/18/2021 9/18/2022 MED EXP,Any one person) $ 10,000 PERSONAL 8.ADV IN,IURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 PRO- X�POLICY E T LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER R AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accide'd1ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) 5 AUTOS AUTOS- NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident( $ - - UMBRELLA LIAB - OCCUR EACH OCCURRENCE $EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER '0TH- AND EMPLOYERS'LIABILITY Y t N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE t E L EACH ACCIDENT 5 O=f ICERJMEMBER EXCLUDED? Li NIA (Mandatory In NH) E L DISEASE-EA EMPLOYEE $ P yes.describe under - DESCRIPTION OF OPERATIONS below E L.DISEASE-POL'CY LIMIT $ B Professional Liability (ESO) ME01453-03 9/18/2021 9/18/2022 Eacn Claim $1,000,000 Policy Aggregate B1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space Is required) CERTIFICATE HOLDER CANCELLATION , SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Information Purposes THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. XXXMODOCCXXMOCCOMODOOLIDa AUTHORIZED REPRESENTATIVE J.J. Wade, III/AH ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD lNS025(2o1aC' • Are J CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOD/YYYY) 08/10/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Leann Abernathi ISU - H.B. Cantrell & Co. c"p( EMI' (704)9644000 _ Trtcx.No): (704)954.9010 1501 E 7th St. MAIL Appant___IsarInfpbcantrell.com Charlotte, NC 28204 INSURER(S)AFFORDING COVERAGE MC* INSURER INSURERA: _Erie Insurance Exchange _ 26271 INSURED INSURER B: Wesc9 Insurance Company Max's Digging Services,Inc INSURERC: 1972 Adam St INSURERD: Conover, NC 28613-8607 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 00005171-0 REVISION NUMBER: 6 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY_ HAVE BEEN REDUCED BY PAID CLAIMS. ILm - -TYPE OF INSURANCE INSD yyyp POLICY NUMBER (MI DIY EYYFWI (IN CDD YYYPYI UNITS A X COMMERCIAL OENERAL UABIUTY Q42-1850642 06/18/2022 06/18/2023 EACH OCCURRENCE $ 1,000,000 DAMAGE-TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 1,000,000_ MED EXP(My one person) $ 5,000_ --�! PERSONAL&ADV INJURY $ 1,000,000_ GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JjECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 _ OTHER _ A AUTOMOBILE IJ"BIUTY Q06-1830619 06/18/2022 06118/2023 (Ea COMBINED SINGLEINGLELIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) ;$ OWNED SCHEDULED BODILY INJURY Per accident) $ AUTOS ONLY X AUTOS ( XHIRED NON-OWNED PROPERTY DAMAGE j $ AUTOS ONLY X AUTOS ONLY (Per accident--_ 1 $ UMBRELLA LMB OCCUR EACH OCCURRENCE I $ EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION$ B AND WORKERPSIOYERSECOMPNSUATIONIUT YIN WWC3590795 06/18/2022 06/18/2023 .X STATUTE _ 100,000_ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 100,000 OFFICER/MEMBER EXCLUDED? N/A — (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ _ 100 000 If yes,desc nbe under —'— r_DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) — CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Shabeldeen Engineering ACCORDANCE WITH THE POLICY PROVISIONS. 3145 Tate Blvd SW HICKORY, NC 28602 AUTHORIZED REPRESENTATIVE ,,#.44.A. (LSA) ©1988-2015 CORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by LSA on 08/10/2022 at 02:41PM