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‘1)L11IN'1'AI2Y RELINQUISHMENT OF ADt<71VIh t IZA'I'I�'h: AI'I'h.;�l. ItI(,11 I ti "'"•..•�- -
Dine prcp.tr.d: 1 U'1 t{'20 i
(twnCitsl: I kit ton Booker .
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Propery location site legal dcs:ia,'ion: Stitih It',t; Leg Rd,Sherrill',Fend Nt. 21673 " t
FIN: le I 002 t,
I MPM venom Permit(IP) 1MPV-O4-2023-193780 .--Uitte Is:...•.d 4ztl'2.Q2?.-_..._.. r .
Authorization to Construct(AC) AUl'11-04-2023 143784 Date i .,ucd i 't7;2023..._-. v>. "'°`'
`, ..4. .,,.
_.` I, ft-CL'I'_'I) ., (►1,il"�,�a);)J Y4untarily relinquish my rights to pursue a formal appeal through the\orth =_
(print full name) ;,:..,—.-•
" Carolina Office of Administrative Hearings pursuant to NC General Statute 130A-24 and 150B-23 and all other applicable ~�
„" provisions of Chapter 150E for the above referenced permits)(which includes the IPs and ACs)in order for the authorized 571- -
agent/local health department to issue the applicable permit(new IP and/or AC)for the site. I understand b) completing this form
that the pennit(s)for a =arse
M..
,1620
—_(System description)
K
will be revoked immediately by the authorized agent/local health department.
I understand that the local health department's revocation of a permit can he appealed to the North Carolina Office of Administrative ,.,�...,..
Hearings within 30 days of the revocation pursuant to the North Carolina Administrative Procedure Act. I understand that in order for
the local health department to issue another IP and AC that the current 11'and AC must be revoked. I understand that the local health
department's revocation of an IP or CA is not effective until 30 days from the revocation or,if the revocation is appealed,at the time
that the Office of Administrative Hearings issues a final deci ion, I understand that by signing this form and relinquishing my right to .be."
i appeal the permit revocation at the Office of Administrative I iearings that the local health department's permit revocation will become
effective immediately. 1 understated and agree that the revocation of a permit that takes effect immediately is in my best interest. I
., understand that by signing this forin that I agree that I do not want to appeal the permit revocation.
.,;
I understand that I am not required to re 'i wish my appeal rights but that this is an option available to me so I do not have to wait 30
"I days for the revocation of the permit t t .c effect.
Signature of Property Ow 7 � /Y)u' (., � �1�1t+G2'
Date Si�tned;_______ .- L,C'�l.,L'('r /(� 2 ',''.5
•
t4CD1114S/DPH/ENS/OSWP hcvixd play 2015 ? `-
catawbacountync.gov
Environmental Health
(OtOw$9 County Governinrli (t:riter
25 Government Drive i'0 Boa 3$9 ( Newlcn NC ?$b58 828 455 8270 �=
AAAVING 111/111t^ DETTED �.
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catawba county
public health
October 18th, 2023
Hettion Booker
226 Palmetto Tree Way
Knightdale, NC 27545
Subject: Notice of Intent to REVOKE the Improvement Permit and Authorization to
Construct for 8666 Dog Leg Rd, Sherrills Ford NC 28673; PIN 461902652526
Catawba County Permits IMPV-04-2023-193780 and AUTH-04-2023-193784
Dear Hettion:
The Environmental Health Division of Catawba County Public Health intends to revoke your
Improvement Permit and Authorization to Construct 30 days from the date of this notice.
If the permits are revoked,you must apply for a new Improvement Permit and Authorization to
Construct(IP/AC) and meet the requirements of the current laws and rules necessary to obtain a new
IP/AC.
You have a right to an informal review of this decision. You may request an informal review by the
environmental health supervisor at the local health department. You may also request an informal
review by the NC Department of Health and Human Services Regional Soil Scientist. A request for
informal review must be made in writing to the local health department.
You also have a right to a formal appeal of this decision. To pursue a formal appeal, you must file a
petition for a contested case hearing with the Office of Administrative Hearings 1711 New Hope Rd,
Raleigh, NC 27609. You may write the Office of Administrative Hearings,call the office at (984) 236-
1850 or get a copy of the petition form from the OAH web site at http://www.oah.nc.gov . The petition
for a contested case hearing must be filed in accordance with the provision of North Carolina General
Statutes 130A-24 and 150B-23 and all other applicable provisions of Chapter 150B. North Carolina
General Statute 130A-335 (g) provides that your hearing would be held in the county where your
property is located.
catawbacountync.gov
Environmental Health
Catowbo County Government Center
25 Government Drive I PO Box 389 I Newton NC 28658 1828.465.8270
MAKING. LIVING. BETTER.
If you wish to pursue a formal appeal, you must file the petition form with the Office of Administrative
Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. The date of this letter is 10/18/2023. Meeting
the 30-day deadline is critical to your formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are
required by law (NC General Statute 150E-23) to serve a copy of your petition on the Office of General
Counsel, NC Department of Health and Human Services, 2001 Mail Service Center, Raleigh, NC 27699-
2001.
Respectfully,
eL)/7,
Robbie Phelps, REHS
Environmental Health Supervisor
Catawba County Public Health
(e:4 )
catawba county
public health
VOLUNTARY RELINQUISHMENT OF ADMINISTRATIVE APPEAL RIGHTS
Date prepared: 10/18/2023
Owner(s): Hettion Booker
Mailing Address: 226 Palmetto Tree Way
Knightdale NC 27545
Property location/site legal description: 8666 Dog Leg Rd, Sherrills Ford NC 28673
PIN: 461902652562
Improvement Permit(IP) IMPV-04-2023-193780 Date Issued:4/17/2023
Authorization to Construct(AC) AUTH-04-2023-193784 Date Issued: 12/17/2023
I, ,voluntarily relinquish my rights to pursue a formal appeal through the North
(print full name)
Carolina Office of Administrative Hearings pursuant to NC General Statute 130A-24 and 150B-23 and all other applicable
provisions of Chapter 150B for the above referenced permit(s)(which includes the IPs and ACs)in order for the authorized
agent/local health department to issue the applicable permit(new IP and/or AC)for the site. I understand by completing this form
that the permit(s)for a
1IIE-50%reduction
(System description)
will be revoked immediately by the authorized agent/local health department.
I understand that the local health department's revocation of a permit can be appealed to the North Carolina Office of Administrative
Hearings within 30 days of the revocation pursuant to the North Carolina Administrative Procedure Act. I understand that in order for
the local health department to issue another IP and AC that the current IP and AC must be revoked. I understand that the local health
department's revocation of an IP or CA is not effective until 30 days from the revocation or,if the revocation is appealed, at the time
that the Office of Administrative Hearings issues a final decision. I understand that by signing this form and relinquishing my right to
appeal the permit revocation at the Office of Administrative Hearings that the local health department's permit revocation will become
effective immediately. I understand and agree that the revocation of a permit that takes effect immediately is in my best interest. I
understand that by signing this form that I agree that I do not want to appeal the permit revocation.
I understand that I am not required to relinquish my appeal rights but that this is an option available to me so 1 do not have to wait 30
days for the revocation of the permit to take effect.
Signature of Property Owner:
Date Signed:_
NCDHHS/DPH/EHS/OSWP Revised May 2015
catawbacountync.gov
Environmental Health
Catawba County Government Center
25 Government Drive I PO Box 389 I Newton NC 28658 1828.465.8270
MAKING. LIVING. BETTER.
4.4`t (Am cot IN II. Cute fit
41 a Public Itealth Department Subdivision SHERWOOD SHORES
�� . _ }s Environmental Ilealth Di. swn I'INU 461902652582
+\/f Pt)liuA 389,25 Gusemment Drnc Noaton,NC 28658 I t)lU 15
tilt Sits Address: 8666 DOG LEG RD, SHERRILLS FORD NC 28873
Name on Pon* HETTION BOOKER
Property Size: Acres 0.47
Directions: NC16, Left onto Balls Creek Rd,right W Bandys Cross Rd, Left Buffalo Shoals Rd, Right E Bandys, Right
Sherrills Ford Rd, Left Mollys Backbone, Right Azalea,Left Dog Leg Rd, Property on Left
Owner/Authorized Representative Acknowledgement of Permit Receipt
lali[ 1tfA I certiti that I am the owner or authorized agent(owner's uuthoriiation required)representing the owner of
the property described atxn e.
0,A As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service RBPR-01-2023-43175,by the following method(s):
•
__ Received in Person
} Facsimile Transmittal(Return form with signature required)
I Electronic Image Transmittal!E-mail (Return receipt required)
As the property owner or authorized representative I have reviewed and understand the specific conditions
)C—
of the permit issued, and further understand that all applicable regulatory requirements specified under the
North Carolina Laws and Rules for Sewage Treatment and Disposal Systems(15A NCAC 18A.1900),
and/or Well Construction Standards(15A NCAC 2C.0100), shall apply to the issuance of this permit and
the construction of the wastewater system and/or water supply well permitted.
Permit Issue Date:04/17/2023
/r
Owner Authorized Representative Signature(\ 1 'Y� ILL/2.).
Date- 4"',21 0 " Q
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by hrunre of'person
( l sending permit)
Signature €..
Date/Time 1 I II i 1` 3
i j
Method: Fax 4 Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
We wantt tto hear from yorPlease ttake a few momentts tto complette our custtomer service survey att
,
http://www.surveymonkey.com/s/EHCusttomerService
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=_• CATAWBA COUNTY Case# IMPV-04-2023-193780
t: ..t.II , , Public Health Department Subdivision SHERWOOD SHORES
Environmental Health Division PIN# 461902652562
PO Box 389.25 Government Drive,Newton,NC 28658 LOIN 15
ia4 sw
Site Address: 8666 DOG LEG RD, SHERRILLS FORD NC 28673
Name on Permit: HETTION BOOKER
Property Size: Acres 0.47
Directions: NC16, Left onto Balls Creek Rd,right W Bandys Cross Rd, Left Buffalo Shoals Rd, Right E Bandys, Right
Sherrills Ford Rd, Left Mollys Backbone, Right Azalea, Left Dog Leg Rd, Property on Left
Improvement Permit
AN AUTHORIZATION TO CONSTRUCT MUST BE ISSUED PRIOR TO BUILDING PERMITS
THIS PERMIT IS NOT FOR SEPTIC INSTALLATION
Permit Category: New Septic Wastewater Flow 240 d
9P
Type of Facility: Primary Residence- New House
Basement? No Basement Plumbing? No Bedrooms: 2
Water Supply: Private Well Maximum Occupants: 4
INITIAL SYSTEM SPECIFICATIONS
Proposed Wastewater System: 50%REDUCTION HORIZONTAL
System Classification: IIIE-PPBPS GRAVITY DOSED SYSTEM
_ ^ _ _ _ REPAIR SYSTEM SPECIFICATIONS
Repair System Required? Not Required
Permit Conditions:
Landscaping or other site alterations that potentially divert groundwater or surface water toward the septic system, or prevent proper
drainage away from the septic system, including the direction of gutter flows or foundation drains,is not approved,and may result in failure to
approve the initial system installation,or the suspension/revocation of existing permits.
The issuance of this permit by the Health Department does not guarantee the issuance of other permits. It is the responsibility of the applicant
/property owner to insure that all Catawba County Planning/Zoning and Building Inspections requirements are met. This Improvement Permit
is subject to revocation if the site plan,plat or the intended use changes.or if site conditions are altered. The Improvement Permit is not
affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina'Laws and
Rules for Sewage Treatment and Disposal Systems' (I5A NCAC 18A.1900). Neither Catawba County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily for any given period of time.
Any permit issued for a conventional system may be used for an accepted system without Environmental Health authorization or permit
modification.Please notify Environmental Health of this change prior to system installation.
.7 filli
04/17/2023
Authorized State Agent Permit Issuance Date
4/17/2028
Permit Expiration Date
No grading or construction activity is allowed in areas designated for system and repair without approval of the Health Department.
ehpenni l 04/18/2023 15:42
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DEPARTMENT OF HEALTH AND HUMAN SBZVICES Sheet of
DIVISION OF PUBLIC HEALTH,ENVIRONMENTAL HEALTH SECTION —
ON-SIITi WATER PROTECTION BRANCH PROPERTY II)4:
COUNTY: Catawba
SOIL/SITE EVALUATION
for ON-SITE WASTEWATER SYSTEM
(Complete all fields in full)
OWNER: Het ' r
ADDRESS: _.. _, APPLICATION DATE
/I1. DATE EVALUATED: ` ! ?C.PROPOSEDFSITE:
FACILITY: PROPOSED N F�) 19¢9 PROPERTY RECORDED; ` ! �J
LOCATION OF SITE: o r-!� )'"/
WATER SUPPLY: 0 Private L Public a ;._Spring fl Other
EVALUATION METHOD:,}0 Au:cr Boring WI' f i Cut TYPE OF WASTE WATER: IYJage L Industrial Process L]Mixed
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DESCRIPTION INITIAL SYSTEM REPAIR SYSTEM OTHER FACTORS(.1946):
Available Space(.1945) LA'< J' �j SITE.CLASSIFICATION(.1948): �__ _
System Typc(s) // vL`/ - EVALUA"TED I3Y: �-
�) OTHER(S)PRESENT:
. Site LIAR i 07 75 s i/ 775 — —
COMMENTS: vv / , 1
Updated February 7014
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• Catawba 9ounty Environmental Health
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Parcel: 461902652562, 8666 DOG LEG RD 1 in=50ft
SHERRILLS FORD, 28673
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Copyright 2021 Catawba County NC
01/11/2023