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AOWE-04-2023-193375.TIF
IZU-OODOILI 63SivI`Gt(4Gov 1 '►`'d gEFTrovi �61 RBPR-03-2023-43802 ''llr�I EF- OOODL"lb! Cotkcehnew row - 6 AOWE-04-2023-193375 yswEa,. P'0 ko.t ROY COOPER•Governor h� J Qfy±t NC DEPARTMENT OF KODY H.KINSLEY•Secretary 111 HEALTH AND '�:,,�- HUMAN SERVICES HELEN WOLSTENHOLME•Interim Deputy Secretary for Health 4� � ,!� =r`-- f MARK T.BENTON•Assistant Secretary for Public Health Division of Public Health COMMON FORM FOR AUTHORIZED ON-SITE WASTEWATER EVALUATOR PERMIT OPTION FOR NON-ENGINEERED SYSTEMS See Instructions for Use in AppendixA Except for"Date received",this Section to be completed by the AOWE in accordance with G.S.130A-336.2 LHD USE ONLY: Initial submittal of this NOI received: 3—22— 23 by 12- /1 Date Initials PART 1:Notice of Intent to Construct(NOI)-Please check all that apply Single System o r ❑Multiple Systems AND ®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.): Adams Homes-AEC, LLC _ Mailing address:3401 St.Vardell Lane, Suite B City:Charlotte _State: NC Zip: 28217 Telephone number: 704-558-4527 _ E-mail Address: bcashioneadamshomes.com 2. Authorized On-Site Wastewater Evaluator(AOWE)name:Jeff Vaughan LSS License number:1227 AOWE Certification number:10003E Mailing address:501 N Salem St, Suite 203 City:Apex State:NC _Zip:27502 Telephone number: 919-859-0669 — E-mail Address: jvaughan(@.aariwaste.com 3. Licensed Geologist(LG)(if applicable)name: License Number: Mailing address: City: State: Zip: Telephone number: E-mail Address: 4. 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: ®AOWE ❑ LG 5. Property location(physical address,tax parcel identification number or subdivision lot,block number of the property to be permitted Let 7C.Penarth Drive, Catawba, NC. 28609 (Cardiff Glyn Subdivision) LOT 75 Amended based on PLAT dated January 26,2023 County Name:Catawba RECEIVED CE1 Y OCT 1 6 2024 NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH LOCATION:5605 Six Forks Road,Raleigh,NC 27609 MAR 2023 MAILING ADDRESS:1642 Mail Service Center,Raleigh,NC 27699-1642 www.ncdhhs.gov • TEL:919-707-5874 • FAX:919-845-3972 Environmental Health AN EQUAL OPPORTUN1 /AFFIRMATIVE ACTION EMPLOYER vironmental He AOWE-04-2023-193375 AOWE Common Form- LHD Reference: 6. Type of facility: ® Place of residence No.Bedrooms:4 _ No.Occupants:8 0 Place of business Basis for flow calculation: 0 Place of public assembly Basis for flow calculation: 7. Factors that would affect the wastewater load:domestic strength wastewater from a single-family residence 8. Type and location of proposed wastewater system:Gravity 25% Reduction drain field product Location shown on site plan 9. Design wastewater flow:480 _gpd Design wastewater strength: ®domestic 0 high strength 0 industrial process(For high strength and industrial process wastewater,a Professional Engineer licensed in accordance with G.S.89Cshall design the on-site wastewater system.) 10. A plat as defined in G.S.130A-334(7a)is attached: ❑Yes ®No A site plan as defined in G.S.130A-334(13a)is attached: ®Yes ❑No 11. 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 15A NCAC 18A.1950: ®Yes ❑No This is a saprolite system. 0 Yes ®No 12. Evaluation(s)of soil conditions and site features in accordance with G.S.130A-335(a1)signed and sealed by a LSS is attached: ®Yes 0 No 13. Evaluation of geologic and hydrogeologic conditions signed and sealed by a LG is attached ❑Yes ® NA 14. Proposed landscape,site,drainage,or soil modifications are attached: ❑Yes ®NA Attestation by AOWE pursuant to G.S.130A-336.2 1,Jeff Vaughan _hereby attest that the information required to be included with Authorized On-Site Wastewater Evaluator(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,and that the proposed system does not require a Professional Engineer,licensed in accordance with G.S.89C,and in accordance with 15A NCAC 18A.1938 and activities determined to be engineering as determined by the North Carolina Board of Examiners for Engineers and Surveyors. March 16, 2023 Signature of Authorized On-Site WastewaterEvaluator Date Owner self-submittal of NO!: I, 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 RECEIVED OCT 1 6 2024 DHHS/EHS/OSWP—AOWE COMMON FORM Updated April 2022 Environmental Health Page 2 of 6 e- AOWE-04-2023-193375 AOWE Common Form LHD Reference: 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 AOWE Permit Option[G.S.130A-336.2(1)J 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 fora 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. RECEIVED OCT 1 6 2024 Environmental Health DHHS/EHS/OSWP—AOWE COMMON FORM Updated April2022 Page 3 of 6 AOWE-04-2023-193375 AOWE Common Form LHD Reference: 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 the notice of intent to construct required pursuant to subsection(b)of this section is complete within five business days after receiving 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 local health department shall notify the owner and list the information needed to complete the notice.The owner may then submit additional information to the local health department to cure the deficiencies in the initial notice.The local health department shall make a final determination as to whether the notice of intent to construct Is complete within five business days after the department receives the additional information.If the local health department fails to act within any time period set out in this subsection,the owner may treat the failure to act as a determination of completeness. The owner shall be able to apply for the building permit for the project upon the decision of completeness of the notice of Intent by the local health department or if the local health department fails to act within the five business day time period." The review for completeness of this Notice of Intent was conducted in accordance with G.S.130A-336.2(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 AOWE 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 Date u 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 AOWE and the Owner on 11+�3 via t%I' hi 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 Ir 1,1;,), 1(-11--23 Print Name of Authorized Agent of the LHD Signature of Authorized Agent of the LHD Date l{F88 'ED OCT 1 6 2024 Environmental Health DHHS/EH5/OSWP—AOWE COMMON FORM Updated April 2022 Page 4 of 6 AOWE Common Form LHD Reference: Re-submittal of NOI with missing items included This Section Is for use by owner to submit items noted as missing during LHD Completeness Review above. Resubmittals must be accompanied by a cover letter from theAOWE LHD USE ONLY: This NOI resubmittal received: by Date Initials Item#from initial NOI Resubmittal description Attestation by AOWE certified in North Carolina pursuant to G.S.130A-336.2 I, hereby attest that the information required to be included with Authorized On Site Wastewater Evaluator(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. Signature of Authorized On-Site Wastewater Evaluator Dote The section below Ls 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- 336.2(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 AOWE 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 Date ❑ 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 AOWE and the Owner on via Date Email,FAX,LISPS,Hand-delivered A complete copy of this form with tracking information was sent to the State: via RECEIVED USPS,hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Date OCT 1 6 2024 DHHS/EHS/OSWP—AOWE COMMON FORM Updated April2022 Environmental Health Page 5of6 AOWE Common Form LHD Reference: PART 3: Authorization to Operate(ATO) Except for date received,the Section below is to be completed by the Owner. LHD USE ONLY: Initial submittal of request for ATO received: by Date initials Date of Post-construction Conference: T The following items are included in this submittal for an Authorization to Operate under an AOWE permit: 1. Signed and sealed copy of the AOWE's report that includes the information in G.S.130A-336.2(k) ❑ Yes ❑ No 2. Operation and management program ❑ Yes ❑ No 3. Fee (as applicable) ❑ Yes ❑ No 4. Notarized letter documenting Owner's acceptance of the system from the AOWE ❑ Yes ❑ No 5. On-site Wastewater Contractor name: License number: Mailing address: City: State: Zip: Telephone number: E-mail Address: 6. Proof of Errors and Omissions or other appropriate liability insurance for the On-site Wastewater Contractor is attached and includes the name of the insurer,name of the insured,and the effective dates of coverage. ❑Yes ❑ No Attestation by the Owner for Authorization to Operate I, hereby attest that all items indicated above have been provided to the Print name of Owner County LHD and the system shall meet applicable federal,State,and local laws, -regulations,rules,and ordinances. Signature of Owner Date This section for LHD Use Only. LHD Review of required information for the ATO ❑ INCOMPLETE Based upon review of information submitted in the Section above,the following items are missing from the information required for an Authorization to Operate for an AOWE permit: Copies of this signed form were sent to the AOWE 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 Date ❑ COMPLETE Based upon review of information submitted in the Section above,this Authorization to Operate is hereby issued in accordance with G.S.130A-336.2(m). A copy of this complete NOI/ATO with tracking information was sent to the State on via Date Email,FAX USPS,Hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Date ire su rsJ ISSUANCE OF CERTIFICATE OF OCCUPANCY:Once the LHD determines completeness based upon ro ,t r 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. 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H-1dNE W o=1oe x I III a L .. ay l ill ii.1 p a `� 2 i Opgl 9p 9fil > q1. aa �`� .:ii,5 \ 2 I. � a .110 ?t-i 0 -5-, c ›.„ . . g <E..1 ,; it., Pip WO asss Z \ -�\ -M-M �M M \ lI ly `Ico o HOUSE 0o ii I \ I I9 gp X6 \ 'i N iI \ 102 i �66 I `.` ` - 1 1 \ \\ III ` .86 1:idgj -� l �I \ 86 wig Ll �\ I _ I 66\ `� 1'`-�\ \`- ;Z06 ai!9M 91 �O\\ 1-8-1.°2 cod i \ NN \` \ �N , t h \ N \ �• \ ZOL pa,S7``\ C t ` �,'N.�Z L �luiq;•`._._, \` 0 1 1 986 w ( •,____ 8L a \rl g8j \ \ _ Il RECEIVE" a Ll \� \\ ' 'OCT 1 6 2(24 \ t G I \ , iT \ \ I , % \Environ mental He:It1 z86 m\ 4,15' ,...„... ..„ \ ♦ \ --. -L „._ „. :). \ \ =ter _ Esj � �\ \ \ o� O 15 61'Ztil \ . , 1 M.LMNOLN \ N -- 086t. , f —� m 1 v \ a°a m ) ` • F- ill O>- ;If .::E\.:::\ s2 ;\ _ '--�.1 m o v '4.1%; /f ® , O n o N o ti rn W c 3 11 / 4 \ - L m ov a o co 0 RBPR-03-2023-43802 AOWE-04-2023-193375 N 0 STATE a do ROY COOPER•Governor 61:r 4'y NC DEPARTMENT OF :, _ KODY H. KINSLEY•HUMAN SERVICES Secretary� S HEALTH AND . HELEN WOLSTENHOLME•Interim Deputy Secretary for Health � =>Q MARK T. BENTON•Assistant Secretary for Public Health Division of Public Health COMMON FORM FOR AUTHORIZED ON-SITE WASTEWATER EVALUATOR PERMIT OPTION FOR NON-ENGINEERED SYSTEMS See Instructions for Use in Appendix A Except for"Date received",this Section to be completed by the AOWE in accordance with G.S.130A-336.2 LHD USE ONLY: Initial submittal of this NOI received: 1— 22 - 23 by P-l" Date Initials PART 1: Notice of Intent to Construct(NOI)-Please check all that apply ®Single System o r ❑ Multiple Systems AND ®New ❑Expansion ❑ Relocation of all or part of the Existing System ❑ Relocation of Repair Area ❑ Repair-LHD Permit Number ❑ Repair-EOP/LSSCOVID19/AOWEPermit Number 1. Facility Owner's name:(Owner, Company Name, Utility, Partnership, Individual, etc.): Adams Homes-AEC, LLC Mailing address: 3401 St. Vardell Lane, Suite B City: Charlotte _State: NC Zip: 28217 Telephone number: 704-558-4527 _ E-mail Address: bcashioneadamshomes.com 2. Authorized On-Site Wastewater Evaluator(AOWE) name:Jeff Vaughan LSS License number:1227 AOWE Certification number:10003E Mailing address:501 N Salem St, Suite 203 City:Apex State: NC _ Zip:27502 Telephone number: 919-859-0669 _ E-mail Address: jvaughan@agriwaste.com 3. Licensed Geologist(LG) (if applicable) name: License Number: Mailing address: City: State: Zip: Telephone number: E-mail Address: 4. 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: AOWE ❑ LG 5. Property location(physical address,tax parcel identification number or subdivision lot, block number of the property to be permitted Lot 76 Penarth Drive, Catawba, NC. 28609 (Cardiff Glyn Subdivision) County Name: Catawba RECEIVED NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH LOCATION:5605 Six Forks Road,Raleigh,NC 27609 MAR 2 2 2023 MAILING ADDRESS:1642 Mail Service Center, Raleigh,NC 27699-1642 www.ncdhhs.gov • TEL:919-707-5874 • FAX:919-845-3972 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER Environmental Health AO W E-04-2023-193375 AOWE Common Form LHD Reference: 6. Type of facility: j Place of residence No. Bedrooms:4 _ No. Occupants:8 ❑ Place of business Basis for flow calculation: ❑ Place of public assembly Basis for flow calculation: 7. Factors that would affect the wastewater load:domestic strength wastewater from a single-family residence 8. Type and location of proposed wastewater system:Gravity 25% Reduction drain field product Location shown on site plan 9. Design wastewater flow:480 _gpd Design wastewater strength: ®domestic ❑ high strength ❑ industrial process(For high strength and industrial process wastewater,a Professional Engineer licensed in accordance with G.S.89Cshall design the on-site wastewater system.) 10. A plat as defined in G.S. 130A-334(7a)is attached: ❑Yes ® No A site plan as defined in G.S. 130A-334(13a)is attached: ®Yes ❑ No 11. 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 15A NCAC 18A.1950: ®Yes ❑ No This is a saprolite system. ❑ Yes ® No 12. Evaluation(s)of soil conditions and site features in accordance with G.S. 130A-335(a1)signed and sealed by a LSS is attached: I Yes ❑ No 13. Evaluation of geologic and hydrogeologic conditions signed and sealed by a LG is attached ❑Yes ® NA 14. Proposed landscape,site,drainage,or soil modifications are attached: ❑ Yes ® NA Attestation by AOWE pursuant to G.S.130A-336.2 1,Jeff Vaughan —hereby attest that the information required to be included with Authorized On-Site Wastewater Evaluator(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, and that the proposed system does not require a Professional Engineer, licensed in accordance with G.S.89C,and in accordance with 15A NCAC 18A.1938 and activities determined to be engineering as determined by the North Carolina Board of Examiners for Engineers and Surveyors. March 16, 2023 Signature of Authorized On-Site Wastewater Evaluator Date Owner self-submittal of NOI: I, 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 DHHS/EHS/OSWP-AOWE COMMON FORM Updated April 2022 Page 2 of 6 AOWE-04-2023-193375 AOWE Common Form LHD Reference: 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 AOWE Permit Option[G.S. 130A-336.2(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—AOWE COMMON FORM Updated April2022 Page 3 of 6 AO W E-04-2023-193375 AOWE Common Form LHD Reference: 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 the notice of intent to construct required pursuant to subsection(b)of this section is complete within five business days after receiving 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 local health department shall notify the owner and list the information needed to complete the notice. The owner may then submit additional information to the local health department to cure the deficiencies in the initial notice. The local health department shall make a final determination as to whether the notice of intent to construct is complete within five business days after the department receives the additional information.If the local health department fails to act within any time period set out in this subsection,the owner may treat the failure to act as a determination of completeness. The owner shall be able to apply for the building permit for the project upon the decision of completeness of the notice of intent by the local health department or if the local health department fails to act within the five business day time period." The review for completeness of this Notice of Intent was conducted in accordance with G.S. 130A-336.2(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 AOWE 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 Nome of Authorized Agent of the LHD Signature of Authorized Agent of the LHD Date 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 AOWE and the Owner on 41 01)3 via 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 y2„ 0,,,fi Pb-jor ."4,, 44— Print Nome of Authorized Agent of the LHD Signature of Authorized Agent of the LHD Date DHHS/EHS/OSWP—AOWE COMMON FORM Updated April 2022 Page 4 of 6 AOWE Common Form LHD Reference: Re-submittal of NOI with missing items included This Section is for use by owner to submit items noted as missing during LHD Completeness Review above, Resubmittals must be accompanied by a cover letter from the ACME. LHD USE ONLY: This NOI resubmittal received: by Date Initials Item#from initial NOI Resubmittal description Attestation by AOWE certified in North Carolina pursuant to G.S.130A-336.2 I, hereby attest that the information required to be included with Authorized On-Site Wastewater Evaluator(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. Signature of Authorized On-Site Wastewater Evaluator 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- 336.2(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 AOWE and the Owner on via Date Email,FAX,LISPS,Hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Date ❑ 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 AOWE 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-AOWE COMMON FORM Updated April 2022 Page 5 of 6 AOWE Common Form LHD Reference: PART 3: Authorization to Operate(ATO) Except for date received,the Section below is to be completed by the Owner. LHD USE ONLY: Initial submittal of request for ATO received: by Date Initials Date of Post-construction Conference: T The following items are included in this submittal for an Authorization to Operate under an AOWE permit: 1. Signed and sealed copy of the AOWE's report that includes the information in G.S. 130A-336.2(k) n Yes [ No 2. Operation and management program LI Yes ❑ No 3. Fee (as applicable) ❑ Yes ❑ No 4. Notarized letter documenting Owner's acceptance of the system from the AOWE ❑ Yes ❑ No 5. On-site Wastewater Contractor name: License number: Mailing address: City: State: Zip: Telephone number: E-mail Address: 6. Proof of Errors and Omissions or other appropriate liability insurance for the On-site Wastewater Contractor is attached and includes the name of the insurer, name of the insured, and the effective dates of coverage. ❑Yes ❑ No Attestation by the Owner for Authorization to Operate I, hereby attest that all items indicated above have been provided to the Print name of Owner County LHD and the system shall meet applicable federal,State,and local laws, regulations, rules, and ordinances. Signature of Owner Date This section for LHD Use Only. LHD Review of required information for the ATO ❑ INCOMPLETE Based upon review of information submitted in the Section above,the following items are missing from the information required for an Authorization to Operate for an AOWE permit: Copies of this signed form were sent to the AOWE 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 Date ❑ COMPLETE Based upon review of information submitted in the Section above,this Authorization to Operate is hereby issued in accordance with G.S. 130A-336.2(m). A copy of this complete NOl/ATO with tracking information was sent to the State on via Date Email,FAX,USPS,Hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Date ISSUANCE OF CERTIFICATE OF OCCUPANCY: Once the LHD determines completeness based upon the ATO 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. DHHS/EHS/OSWP—AOWE COMMON FORM Updated April 2022 Page 6 of 6 �—mqi AGRITEC-01 GKROHL ACORD' DATE(MMIDD YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 3/14/2023 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 Connie Garkalns Hartsfield&Nash Agency,Inc. 10405 Ligon Mill Rd.,Ste H PHONE�M ,Eat):(919)556-3698 �FAX No):(919)556-8758 Wake Forest,NC 27587 ADDREss:Connie@hartsfield-nash.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Selective Insurance Company of the Southeast 39926 INSURED INSURER B:ACCIDENT FUND INSURANCE COMPANY OF AMERICA 10166 Agri-Waste Technology Inc INSURER C:Evanston Insurance Company 501 N.Salem St Ste 203 INSURER 0: Apex,NC 27502 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADM SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD, IMM/DDIYYYYI (MM/DDIYYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR S 2253659 1/18/2023 1/18/2024 DAMAGETORENTED 300,000 PREMISES fEa occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY X !E LOC PRODUCTS-COMP/OPAGG $ 4,000,000 OTHER: $ COMBID A AUTOMOBILE LIABILITY Ea accident SINGLE LIMIT $ 1,000,000 X ANY AUTO S 2253659 1/18/2023 1/18/2024 BODILY INJURY(Par person) $ - OWNED — SCHEDULED AUTOS AUTOpS ONLY AUTOS W p BODILY INJURY(Per accident) $ — — AUTOS ONLY _ OS ONr Y (Perr acciidentDAMAGE $ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-MADE S 2253659 1/18/2023 1/18/2024 AGGREGATE $ 2,000,000 DED RETENTION$ $ B WORKERS COMPENSATION Xy PER STATUTE 0TH AND EMPLOYERS'LIABILITY 100003072 1/18/2023 1/18/2024 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE ER YNN N/A E.L.EACH ACCIDENT J OFFICER/MFIMBT2 EXCLUDED? (Mandatory n ) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Prof&Pollution MKLV3ENV103400 8/22/2022 8/22/2023 Each Claim 5,000,000 A Leased I Rented S 2253659 1/18/2023 1/18/2024 Equipment 25,000 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 "This is ONLY For Informational Purposes THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. Contact Agency for Specific Holder info to be added AUTHORIZED REPRESENTATIVE Ai NA..Killt4 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD J Engineers and Soil Scientists 1:1111 Agri-Waste Technology, Inc. 501 N. Salem Street, Suite 203 Apex. North Carolina 27502 1 _ 919-859-0669 _ • , www.agriwaste.com Soil Suitability for Domestic Sewage Treatment and Disposal Systems Lot 76 Penarth Drive, Catawba, NC. 28609 Cardiff Glyn Subdivision (Catawba County) PREPARED FOR: Adams Homes—AEC, LLC, Client PREPARED BY: Jeff Vaughan, Senior Agronomist& Soil Scientist Trevor Hackney,Environmental Scientist DATE: March 16, 2023 Soil suitability for domestic sewage treatment and disposal systems was evaluated on September 12, 2022, for the proposed property located at Lot 76 Penarth Drive, Catawba, NC. Jeff Vaughan and Trevor Hackney of Agri-Waste Technology, Inc. (AWT) conducted the soil evaluation. This evaluation was done to facilitate permitting for a septic system. This report and attached documents were prepared to meet the requirements for an Authorized On-Site Wastewater Evaluator to meet G.S. 130A-336.2 A drawing of the site plan, septic layout, and boring locations is included in Attachment 1. Profile descriptions for each boring are included in Attachment 2. Additional documentation about the property is included in Attachment 3. This property is a subdivision of a larger property that will make up the Cardiff Glyn subdivision. This property area is approximately 0.93 acres. The property is an open grass field. The home is proposed near the front property line and the septic system is proposed towards the back of the property. The proposed septic system is a conventional gravity septic system utilizing a 25%reduction product. Soil Suitability for Domestic Sewage Treatment and Disposal Systems The drawing in Attachment 1 details the property boundaries (as proposed by Frank Craig), soil boring locations, and layout of drain field trenches (Completed by AWT). Four soil borings were assessed on the property. Soil borings were examined to determine soil suitability for on-site sewage disposal systems in accordance with 15A l 8A .1900 Rules for Sewage Treatment and Disposal Systems. These borings were advanced with a hand auger. All soil borings are useable for a conventional style trench and are being utilized for the drain field area. 1 A septic layout was performed to demonstrate available space(.1945). The layout in Attachment 1 indicates there is available space for a four-bedroom primary and repair system utilizing a 25%reduction drain field product. The proposed LIAR(Long Term Acceptance Rate) by AWT is 0.3 GPD/ft2. The soils on this property are group IV soils within the distribution and treatment zone as used to define the LTAR. Since usable slope corrected soil depths meet or exceed 32" AWT is recommending the use of the 25%reduction product. With an LTAR of 0.3 GPD/ft2, 800 linear feet of trench are necessary to support a four-bedroom home initial and repair system. The maximum trench bottom should not exceed 20". The attached drawing proves that 400 linear feet of trench can be installed for the primary septic system and 400 linear feet of trench can be installed for the repair septic system with the proposed home location on the property. Any disturbances or grading done in the usable area or within the proposed setbacks will change the potential of using the area designated for a drain field. We appreciate the opportunity to assist you in this matter. Please contact us with any questions, concerns, or comments. Sincerely, Jeff Vaughan, AOWE /40 ig4 Attachment 1: Site Plan/Drawing and Calculations = Y j o o o r A•a Ea:` `-:. , I ,� z.• < 3 N • tr 1' T} - f — >.w al +. Cl) �. 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Lot#: 76 Permit#: Project Manager: Owner: Adams Homes-AEC, LLC Jeff Vaughan, PhD, LSS Address: 3401 St.Vardell Lane,Suite B Type of System: II a jvaughan@agriwaste.com Charlotte, NC 28217 919-859-0669 Phone: 704-558-4527 Engineer: Email: bcashion@adamshomes.com PIN: 378003016801 Rodney L. Huffman, PhD, PE rhuffman@agriwaste.com EHS: Soil Parameters Soil Evaluation By: Special Conditions/Notes: LIAR: 0.30 gpd/ft2 Design Parameters Type of Establishment: Residence,5 or fewer bedrooms Unit: Bedroom #of Units: 4 Septic Tank Specifications Min.Tank Capacity: 1,000 gal Exterior Interior Actual Tank Volume: 1,250 gal Length: 125.5 119.5 in. Tank Manufacturer: Shoaf Width: 65.5 59.5 in. Tank Model: TS 1250 STB Depth: 61.5 54.5 in. Primary Draintield Specifications Type of Distribution: Serial Drop Box Trench Bottom Area: 1600 ft2 Trench Media: Chambers Minimum Drain Line: 400 ft Trench Width: 3 ft Actual Drain Line: 400 ft Trench Depth: in. Number of Lines: 4 (or as specified on permit) Minimum Line Spacing: 9 ft O.C. II Wastewater Treatment System Design Calculations Project: Cardiff Glyn - Lot 76 Location: 5064 Throneburg Rd Catawba, NC 28609 County: Catawba Septic Tank Sizing Daily Flow Estimate: Unit #of Units Flow/Unit Flow/Day Bedroom 4 120 480 0 0 Q= 480 gpd Septic Tank Minimum Capacity: Per NCAC T15A:18A ,1952(b)(1): For individual residences with 4 bedrooms, Minimum Liquid Capacity (V)= 1,000 gal Septic Tank Specs: Manufacturer: Shoaf Model: TS 1250 STB Volume: 1,250 gal Weight: 11,000 lbs Exterior Interior Length: 125.5 119.5 in. Width: 65.5 59.5 in. Depth: 61.5 54.5 in. Shape of Risers: Circular Diameter: 2.00 ft _ I ELEVATIONS Project: Cardiff Glyn - Lot 76 Location: 5064 Throneburg Rd Catawba, NC 28609 County: Catawba Benchmark IP NE corner Lot 1 BM Elev 993.72 ft Septic Tank 1,250 gal Ground Surface 994.41 ft Depth of Soil Cover 12 in. 1.00 ft Overall Ht of Tank 61.5 in. 5.13 ft Elev, Base of Tank 988.29 ft Ht to 4" Inlet Invert 50 in. 4.17 ft Elev, 4" Inlet Invert 992.45 ft Ht to 4" Outlet Invert 48 in. 4.00 ft Elev, 4" Outlet Invert 992.29 ft Gravel Base 6 in. 0.50 ft Elev, Bot of Excavation 987.79 ft ST Inlet Pipe Grade @ Stub-out 995.41 ft Depth of Stub-out, top 1.5 ft Elev, Stub-out Invert 993.56 ft Elev @ ST Inlet Invert 992.45 ft Length 15 ft Slope 7.4 % • Drainfield Design Project Cardiff Glyn-Lot 76 Location 5064 Throneburg Rd Catawba,NC 28609 County Catawba Drainfield Sizing Primary LTAR 0.3 gpd/ft2 Daily Design Flow 480 gpd Type of Drainfield Media Chambers Req.Drainfield Area 1,600 ft2 Required Drainline Trench Width,Eff. 3 ft After 25%Reduction 400 ft Required Drainline 533 ft Minimum Line Spacing 9 ft(O.C.) Repair LIAR 0.3 gpd/ft2 Daily Design Flow 480 gpd Type of Drainfield Media Chambers Req.Drainfield Area 1,600 ft2 Required Drainline Trench Width,Eff. 3 ft After 25%Reduction 400 ft Required Drainline 533 ft Minimum Line Spacing 9 ft(O.C.) Drainfield Layout Elevation Line Length Used as Used as One Use Flag Color (ft) (ft) Primary(ft) Repair(ft) 1 Layout Line red 987.9 76 74 2 Layout Line white 988.7 106 106 3 Layout Line blue 989.6 132 118 4 Layout Line pink 990.5 149 102 5 Layout Line red 991.7 168 102 6 Layout Line white 992.8 142 102 7 Layout Line blue 993.1 114 98 8 Layout Line pink 993.6 117 98 Total 1004 400 400 Count 8 4 4 Note:Line length totals are shown to the nearest foot. Line lengths shown in drawings include 2'for endcaps. For Chambers or Low-profile Chambers: Effective trench lengths are shown.Add 1'for total installation length. J I Attachment 2: Soil Boring Description Sheets COUNTY:Catawba Co._ SOIL/SITE EVALUATION for ON-SITE WASTEWATER SYSTEM (Complete all fields in full) CLIENT: Adams Homes _APPLICATION DATE ADDRESS: Lot 76 Penarth Drive DATE EVALUATED: 9/12/22_ _ PROPOSED FACILITY:_Single Family Residence PROPOSED DESIGN FLOW(.1949): 480 GPD PROPERTY SIZE: .93 ac. LOCATION OF SITE: Lot 76 Penarth Drive PROPERTY RECORDED: WATER SUPPLY: ❑Private XPublic ❑ Well ❑Spring 0 Other EVALUATION METHOD: X Auer Boring ❑Pit 0 Cut TYPE OF WASTEWATER: X Sewage ❑Industrial Process ❑Mixed SOIL MORPHOLOGY OTHER F (.1941) PROFILE FACTORS .1940 LANDSCAPE HORIZON POSITION/ DEPTH PROFILE # SLOPE% (IN.) .1942 CLASS .1941 .1941 SOIL .1943 .1956 .1944 STRUCTURE/ CONSISTENCE/ WETNESS/ SOIL SAPR RESTR <AR TEXTURE MINERALOGY COLOR DEPTH co HORIZ CLASS 0-12" SCL;GR SS;SP;FR - 36" - - Provisionally 8% Suitable 12-36+" C;SBK SS;SP;FI SB 0.3 0-10" SCL;GR SS;SP;FR - 36' - - 10% Provisionally SB 10-36" C;SBK SS;SP;Fl Suitable 2 0.3 • 0-20" SCL;GR SS;SP;FR 36' Provisionally 10% Suitable SB 20-36" C;SBK SS;SP;FI 3 0.3 SB 0-10" SCL;OR SS;SP;FR 36" Provisionally 8% Suitable 4 10-36" C;SBK SS;SP;FI 0.3 DESCRIPTION INITIAL SYSTEM REPAIR SYSTEM OTHER FACTORS(.1946): SITE CLASSIFICATION(.1948): Available Space(.1945) Provisionally Provisionally Suitable Suitable EVALUATED BY: Jeff Vaughan System Type(s) Conventionalo ConventionalQ OTHER(S)PRESENT: Trevor Hackney 25%Reduction 25%Reduction Site LTAR 0.3 GPD/Ft2 0.3 GPD/Ft2 COMMENTS Updated February 2014 IP- LEGEND use the following standard abbreviations SOIL CONVENTIONAL LPP MINERALOGY/ LANDSCAPE POSITION GROUP TEXTURE ,1955 LTAR* ,1957 LTAR* CONSISTENCE STRUCTURE CC(Concave Slope) I S(Sand) 1.2-0.8 0.6-0.4 SEXP(Slightly Expansive) G(Single Grain) CV(Convex Slope) LS(Loamy Sand) EXP(Expansive) M(Massive) D(Drainage Way) CR(Crumb) DS(Debris Slump) II SL(Sandy Loam) 0.8-0.6 0.4-0.3 GR(Granular) FP(Flood Plain) L(Loam) SBK(Subangular Blocky) FS(Foot Slope) ABK(Angular Blocky) H(Head Slope) III Si(Silt) 0.6-0.3 0.3-0.15 PL(Platy) L(Linear Slope) SiCL(Silty Clay Loam) PR(Prismatic) N(Nose Slope) CL(Clay Loam) R(Ridge) SCL(Sandy Clay Loam) MOIST WET S(Shoulder Slope) SiL(Silt Loam) T(Terrace) VFR(Very Friable) NS(Non-sticky) IV SC(Sandy Clay) 0.4-0.1 0.2-0.05 FR(Friable) SS(Slightly Sticky) SIC(Silty Clay) F1(Firm) S(Sticky) C(Clay) VFI(Very Firm v.Very Sticky) VS(Very Sticky) 0(Organic) None None EFI(Extremely Firm) NP(Non-plastic) SP(Slightly Plastic) *Adjust LTAR due to depth,consistence,structure,soil wetness,landscape,position,wastewater flow and quality. P(Plastic) NOTES VP(Very Plastic) HORIZON DEPTH In inches below natural soil surface DEPTH OF FILL In inches from land surface RESTRICTIVE HORIZON Thickness and depth from land surface SAPROLITE S(suitable)or U(unsuitable) SOIL WETNESS Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less-record Munsell color chip designation CLASSIFICATION S(Suitable),PS(Provisionally Suitable),or U(Unsuitable) Evaluation of saprolite shall be by pits. Long-term Acceptance Rate(LTAR):gal/day/ft2 Show,rofile locations and other site features dimensions,reference or benchmark,and North — ■■■■■■■■n ■■ ■ ■ ■ _ . ■■n tillitillilliglit1111111111111.11111III 1111111111.111111111.111111110111.11.1111111 ■■■■ ■■■■■ ■ ■ ■■■ LI- IIIIIIIIIIMIINIMIIIIIUIIIIMIIIIIIIM ■■n inilippliii,11,11,1,111,111T iiiii ■ ■ ■■■■ ■■■ ■■ ■■■—■ ■■■■■■- ■ ■■ ■■■ ■■■■ ■ IN III _ _■■■ ■■■ ill _■ ■■■ ■ ■ COMMENTS: Updated February 2014 Attachment 3: Additional Documentation . 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