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EOP-07-2023-200371
yO .v Uv . 7 Engineer Option Permit Common Form LHD Reference:' _2��_- PART 3: Authorization to Operate(ATO) Except for date received,the Section below is to he completed by the Owner or the PE. LHD USE ONLY: Initial submittal of request for ATO received: 1 1/16/23 by iv\F\ , t Dote Initiols Date of Post-construction Conference: W O l\ie,(� Post-construction Conference waived in accordance with G.S. 130A-336.1(j): lvvli T he 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 the information in G.S. 130A-336.1(k)(1) and 15A NCAC 18A.1971(f) ❑X Yes ❑No 2. Operation and management program and ORC contract, if applicable ❑X Yes ❑ No 3. Fee (as applicable) ❑X Yes ❑ No 4. Notarized letter documenting Owner's acceptance of the system from the PE 0 Yes ❑No 5. Owner meets requirements of ownership or control of the system per 15A NCAC 18A.1938(j) 0 Yes ❑ No 6. Easement, right of way, or encroachment agreement required per 15A NCAC 18A.1938(j) ❑Yes E No 7. Multi-party agreements required,as applicable, pursuant to 15A NCAC 18A. .1937(h) ❑Yes 0 No If yes,agreements filed in County Register of Deeds in Deed Book Page Attestation by the Owner or the PE for Authorization to Operate I, George D. Barrier _hereby attest that all items indicated above have been provided to the Print name of Owner or Professional Engineer Catawba 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). 16*- 15NOV13 Signature of Owner or Professional Engineer Date This section for LHD Use Only. !HD 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 EOP: _ 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 LAD Signature of authorized Agent of the LHD Dote ® COMPLETE Based upon review of information submitted in the Section above,this Authorization to Operate is hereby issued in accordance with G.S. 130A-336.1(m). A copy of this complete NOI/ATO with tracking information wa sent o the S(('tt��ate on N/A via ` y Date Email,FAX LISPS,Hond-delivered Megen McBride ��� InV^T _^ 11/16/23 Print name of authorized Agent of the LHD Signat of authorize gent 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. OHHS/EHS/OSWP—LOP COMMON FORM Updated April 2022 Page 6 of 6 Co —I Woop... NL a 3 N Ww m d5 ' 0 2. mwd U o z g Z co ro F. row N Z nY Nm p � 00 Z o NmN D3 � C m o SO ( al 10 J). m < - D , m3= a * — ° >n mN -+ r m e mX � Dr X nv� nZ O n� TZr r r X Z 'A (Am o D <a x mr CD5m 2_ D O Z VI cmwo -I mmc LA I 64 D� no I p44o fl4 tin, ,4p4mo D vO� o w mI . ZfA m mI mm 23 Bm c O coX Z W„ cn !pano I z0 coO wpmx .it I N'o N CO W 8 O NO S \ o wNQ Uo m 0. m En \ Ic a, \ co m, U • ya C O WzN OO M mU U c n/H I o / / q CO cn- p 13 •., n v o CO 4'0 O . p'••. .p: s P N -< CA • �a:�, R�•a:y t n z$ mNi -gym R <. 03 tc ;Z �1 fA. n - n a 2 E v o • fin-- CA: A : D �� � D q m g m CO z R ti .. .�•••° •• ' w ro W ❑ L J November 15, 2023 Dennis Hardin 3735 Shank Tipps Road Lawndale, NC 28090 RE: Owner's acceptance of the system from the PE 3735 Shank Tipps Road, Lawndale, NC 28090 (Catawba County Parcel: 265701068119) The system installed on my referenced property was engineered by Carolina Septic Systems, PC and installed by JW Construction. I, as property owner, do hereby accept the septic system installed on my property. Sincerely, by i �w aaj Dennis Hardin Notary (_,)SvCiLak 7cidiftht, �f COrobn i33tOn e/ fires - 1.1" ` .�� •�6tARy. 9y p: Y. r Rua�` 2 '''� 9kE.Cod �``� On-site Wastewater Contractor's signori statement RE 3735 Shank Tipps Road,Lawndate,NC 28090 (Catawba County Parcel.265701068119) Our company,JW Construction, installed the septic system at the above referenced site. The system was installed in general accordance with the manufacturers'recommendations and permitting plans prepared by Carolina Septic Systems, PC. The system has been start-up tested and is installed to function properly as designed JW Construction by • v ` 161- 75 am ate. � � W, I-IDIbEA toO O7-2,02;2—Zoo3'1 „,i STATE q. do ROY COOPER•Governor gj o 'y NC DEPARTMENT OF KODY H.KINSLEY•Secretary J" ► ' HEALTH A N D "`e,=� HUMAN SERVICES HELEN WOLSTENHOLME• Interim Deputy Secretary for Health MARK T.BENTON•Assistant Secretary for Public Health Division of Public Health COMMON FORM FOR ENGINEERED OPTION PERMIT revised 08SEP23 See Instructions for Use in Appendix A * indicates revisions 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: by Date Initials PART 1:Notice of Intent to Construct(NOI)-Please check all that apply ❑� Single System or ❑ 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.): Dennis and Connie Hardin Mailing address: PO Box 395 City: Valdese State: NC Zip: 28690 Telephone number: (828) 368-3028 E-mail Address: corders1980@gmail.com 2. Professional Engineer(PE)name:George D. Barrier License number: 019221 Mailing address: PO Box 26072 City: Charlotte State: NC Zip: 28221 Telephone number: (704) 201-1487 E-mail Address: CarolinaSepticSystems@carolina.rr.com 3. Licensed Soil Scientist(LSS) name: Larry Thompson, LSS License number: Mailing address: PO Box 541 City: Midland State: NC Zip: 28107 Telephone number: 704-301-4881 Email Address: tarry@thomps0nenv.com 4. Licensed Geologist(LG)(if applicable)name: License number: Mailing address: City: State: Zip: Telephone number: E-mail Address: 5. On-Site Wastewater Contractor name: JW Construction* License number: 5250* Mailing address: PO Box 461* City: Hiddenite* State: NC* Zip: 28636* Telephone number: (828) 469-8008* E-mail Address: jwconstruction8008@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: ❑Q PE ❑■ LSS ❑ LG Q 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/AFFIRMATIVE ACTION EMPLOYER (PAGE 1 ONLY) e CATA BA(OI'N r1'' _ Case# WF I.1-08-2023-203436 (� Public Ilcalth Department Subdivision .� 1� Invirunmenwl Ilealth Division PINU 265701068119 +..'.4 PO Box 389,25 Government Drive,Ne*won.NC 2t565N inn Site Address: 3735 SHANK TIPPS RD, LAWNDALE NC 28090 Name on Permit: *CLAYTON HOMES OF CONOVER#81 (UNLICENSED GC- BILLING ACCT) Property Size: Acres 1.02 Directions: Hwy 18 N Left Roger Hill, Left Pea Ridge Rd, Right Shank Tipps Rd on Left Owner/Authorized Representative Acknowledgement of Permit Receipt VI certify that I am the owner or authorized agent(owner's authorization required)representing the owner of the property described above. P 1)1/ . As the property owner or authorized representative, I have received the above referenced permit(s)as requested in the application for service RBPR-06-2023-44798,by the following method(s): Received in Person Facsimile'Transmittal (Return form with signature required) I Electronic Image Transmittal/ E-mail (Return receipt required) rm, As the property owner or authorized representative I have reviewed and understand the specific conditions of the permit issued, and further understand that all applicable regulatory requirements specified under the North Carolina Laws and Rules for Sewage Treatment and Disposal Systems(15A NCAC 1 SA.1900), and/or Well Construction Standards(I5A NCAC 2C.0100), shall apply to the issuance of this permit and the construction of the wastewater system and/or water supply well permitted. Permit Issue Date:08/25/2023 Owner/Authorized Representative Signature Date__ : " 4-ofs Documentation of Permit(s)Transmittal (permit transmitted by electronic or other means) Permit transmitted by (name ofpersonVA) seending permit) Signature_ 4€________ Date/Time }3 Method: Fax J ,Email US Mail Other Owner's request to send by the above indicated method of transmittal in lieu of signature We wantt tto hear from yoaPlease ttake a few momentts tto complette our custtomer service survey att http://www.surveymonkey.com/s/EtICusttomerServIce matt- v ait61`t`/C"IaL i,I►to1.(.atrt chpcmui (15,282023 12 07 STATE a"., ; ,� ,,,,,>,», iv. ROY COOPER•Governor .,tip �"y; NC DEPARTMENT OF KODY H.KINSLEY•Secretary i •- i HEALTH AND — t HELEN WOLSTENHOLME • Interim Deputy Secretaryfor Health =g, HUMAN SERVICES pry " N�^gip./ MARK T. BENTON•Assistant Secretary for Public Health Division of Public Health COMMON FORM FOR ENGINEERED OPTION PERMIT revised 08SEP23 See Instructions for Use in Appendix A * indicates revisions 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 NOl received: by _ Dote initials PART 1:Notice of Intent to Construct(NOI)-Please check all that apply ■❑Single System or ❑ Multiple Systems AND . New 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.): Dennis and Connie Hardin Mailing address: PO Box 395 City: Valdese State: NC Zip: 28690 Telephone number: (828) 368-3028 Email Address: corders1980@gmail.com 2. Professional Engineer(PE)name:George D. Barrier License number: 019221 Mailing address: PO Box 26072 City: Charlotte State: NC Zip: 28221 Telephone number: (704) 201-1487 E-mail Address: CarolinaSepticSystems@carolina.rr.com 3. Licensed Soil Scientist(LSS)name: Larry Thompson, LSS License number: Mailing address: PO Box 541 City: Midland State: NC Zip: 28107 Telephone number: 704-301-4881 E-mail Address: tarry@thompsonenv.com 4. Licensed Geologist(LG)(if applicable)name: License number: Mailing address: City: State: Zip: Telephone number: E-mail Address: 5. On-Site Wastewater Contractor name: JW Construction* License number: 5250* Mailing address: PO Box 461* City. Hiddenite* State: NC* Zip: 28636* Telephone number: (828) 469-8008* E-mail Address: lwconstruction8008@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 ❑■ LSS ❑ LG ❑■ On-site Wastewater Contractor RECEIVED NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH �] LOCATION:5605 Six Forks Road,Raleigh,NC 27609 S E P 8 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 (PAGE 1 ONLY) A o® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD YYYV) 06/30/2023 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 Hope Murdock NAME: Triangle Insurance Agency PHONE E%t): (704)528-4556 FAX No): (704)528-3909 P.O.Box 30 E-MAIL HOPE@TRIANGLEOFTROUTMAN COM ADDRESS: 275 S.Main Street INSURER(S)AFFORDING COVERAGE NAIC 0 Troutman NC 28166 INSURER A: Atlantic Casualty Insurance Company 42846 INSURED INSURER B: Progressive Southeastern 38784 JW CONSTRUCTION INSURER C: PO BOX 461 INSURER D: INSURER E HIDDENITE NC 28636 INSURER F. COVERAGES CERTIFICATE NUMBER: CL2111405488 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 SU BR POLICY NUMBER POLICY EFF POLICY EXP LTR INS° WVD (MM/DD/YYYYL (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A Y L 001050310-0 06/28/2023 06/28/2024 PERSONAL aADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE $ 2'000000 X POLICY PRO- 1,000,000 JECT LOC PRODUCTS-COMP/OP AGG $ OTHER. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ g — OWNED X SCHEDULED Y 963079912 11/03/2022 11/03/2023 BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY — AUTOS ONLY (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) EL DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule.may be attached it more space is required) RECEIVED SEP ? 2023 CERTIFICATE HOLDER CANCELLATION Environmental Health SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN CMH HOMES INC ATTN:RETAIL ACCT PAYABLE ACCORDANCE WITH THE POLICY PROVISIONS. PO BOX 9790 AUTHORIZED REPRESENTATIVE MARYVILLE TN 37802 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Julia English From: George Barrier <gbarrier@carolinasepticsystems.com> Sent: Friday, September 8, 2023 8:59 AM To: Julia English Cc: Vaughn, Matt; JW Construction Subject: 3735 Shank Tipps Road Attachments: EOP Common Form 3735 Shank Tipps Rd 13JUN23 revised page 1 08SEP23.pdf; ACORD Form 20230630-110658.pdf This is an external email. Please be cautious before clicking any links or attachments. If you have questions about this email, please send them to suspiciousemailnu catawbacountync.2ov Julia, We have changed the septic contractor for the EOP for the system at 3735 Shank Tipps Road. This is the first time I have attempted to revise a Common Form for a permit in Catawba County. So, I need your help again. I have revised the Common Form to now indicate JW Construction and Jeff Holder's info. But, I have only attached page 1 of the form, because I couldn't edit the owner signed copy. I have also attached Jeff's COI. If that will complete your file, or if you need anything else from me, please let me know. Thanks, Don George D. Barrier, PE Carolina Septic Systems, PC PO Box 26072 Charlotte, North Carolina 28269 (o) (980)819- 1811 (c)(704)201-1487 http://carolinasepticsystems.com/ sT�rr.q l�U 0-7- 2 U L 2 00 ROY COOPER • Governor i ,+ � . NC DEPARTMENT OF KODY H. KINSLEY•Secretary ,�G £'- HEALTH AND r: HUMAN SERVICES HELEN WOLSTENHOLME • Interim Deputy Secretary for Health • "`•"' 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: I — z -43 by ler Dare Initials PART 1:Notice of Intent to Construct(NOI)-Please check all that apply Q Single System or ❑ Multiple Systems AND El 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.): Dennis and Connie Hardin Mailing address: PO Box 395 City: Valdese State: NC Zip: 28690 Telephone number: (828) 368-3028 E-mail Address: corders1980@gmail.com 2. Professional Engineer(PE)name:George D. Barrier 019221 g License number: Mailing address:PO Box 26072 City: Charlotte State: NC Zip: 28221 Telephone number: (704) 201-1487 E-mail Address: CarolinaSepticSystems@carolina.rr.com 3. Licensed Soil Scientist(LSS)name: Larry Thompson, LSS License number: Mailing address:PO Box 541 City: Midland State: NC Zip: 28107 Telephone number: 704-301-4881 E-mail Address: larry@thompsonenv.com 4. Licensed Geologist(LG)(if applicable)name: License number: Mailing address: City: State: Zip: Telephone number: E-mail Address: 5. On-Site Wastewater Contractor name: Juan Carlos RoCha License number: 5240 Mailing address: 2602 Gold Mine Road City: Monroe State: NC Zip: 28081 Telephone number: 704-242-3202 E-mail Address: carlosseptic@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: 0 PE 0 LSS ❑ LG 0 On-site Wastewater Contractor RECEIVED NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH LOCATION.5605 Six Forks Road,Raleigh,NC 27609 J U N 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 Engineer Option Permit Common Form LHD Reference: ,0P- 07 2823-2d o3 71 7. Property location(physical address,tax parcel identification number or subdivision lot,block number of the property to be permitted): 3735 Shank Tipps Road, Lawndale, NC Parcel ID: 265701068119 County Name: Catawba 8. Type of facility: Q Place of residence No. Bedrooms: 4 No.Occupants:2 ❑ Place of business Basis for flow calculation: ❑ Place of public assembly Basis for flow calculation: 9. Factors that would affect the wastewater load: Design is for domestic wastewater strength only. 10. Type and location of proposed wastewater system: Septic tank to gravity flow conventional chamber system system located immediately behind the home. System Type We. y 11. Design wastewater flow: 480 gpd(For flow>3,000 gpd/ and industrial process,duplicate plans shall be sent to the State.) Design wastewater strength: Q domestic ❑high strength ❑industrial process 12. A plat as defined in G.S. 130A-334(7a)is attached: Q 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 compiles with 1SA NCAC 18A.1950: Q Yes ❑No This is a saprolite system. ❑Yes IL No 14. Evaluation(s)of soil conditions and site features in accordance with G.S.130A-335(a1)signed and sealed by a LSS is attached: Q Yes ❑No 15. Evaluation of geologic and hydrogeologic conditions signed and sealed by a LG is attached ❑Yes El NA 16. Proposed landscape,site,drainage,or soil modifications are attached: 0 Yes ❑ NA Attestation by Professional Engineer licensed In North Carolina pursuant to G.S.89C 1, George D. Barrier hereby attest that the information required to be included with Registered Professional Engineer(Print Nome) 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). .4 / 7 13JUN23 Signature of Licensed Professional Engineer Date DHHS/EHS/OSWP-EOP COMMON FORM Updated April 2022 Page 2 of 6 . r • 1 r r Engineer Option Permit Common Form LHD Reference: £oe-07'2 D23^700'3 This section is for Owner use to either designate PE as their legal representative or to self-submit the NOI. Designation of Registered Professional Engineer as legal representative of Owner for this Notice of intent: Dennis and Connie Hardin hereby designate George D. Barrier, PE Print Nome 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. Av../ � i� ?icy 13JUN23 Signature of Owner 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.5.130A-336.1. Signature of Owner Date NOTES: LIABILITY: The Department, the Department's authorized agents, or local health departments shall hove no liability for wastewater systems designed,constructed,and installed pursuant to an Engineer Option Permit[G.S. 130A- 336.1(fJJ 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, DNHS/EHS/OSWP-EOP COMMON FORM Updated April2022 Page 3 of 6 Engineer Option Permit Common Form LHD Reference: 1.07-202 7-ZUv 3 1 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 deportment 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 o final determination as to whether the notice of intent to construct is complete within 10 business days after the deportment receives the additional information from the owner or professional engineer. If the deportment 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 Dote 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 Dote COMPLETE(If box is checked,information in this section is required.) Based upon review of information submitted in Part 1 of this form,this N*OI is deemed COMPLETE. Copies of this signed form were sent to the design PE and the Owner on 1 II1I)3 via � ''1.tf Dote Email,FAX USPS,hand-delivered A copy of this NOI and tracking information was sent to the State on via Dote 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 4 of 6 Engineer Option Permit Common Form LHD Reference: 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(HD Completeness Review above. Resubmittais must be accompanied by a rover letter from the PE. LHD USE ONLY: This NOI resubmittal received: by Date Initials Item N from initial NOI Resubmittal description Attestation by Professional Engineer licensed In North Carolina pursuant to G.S.89C I, hereby attest that the information re-submitted for this Notice of Licensed Professional Engineer(Print Nome) 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 Deportment 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 Dote 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 PE and the Owner on via Dote Email,FAX,USPS,Hand-delivered A complete copy of this form with tracking information was sent to the State: via Dote Email,FAX LISPS,hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHO Date DHHS/EHS/OSWP-EOP COMMON FORM Updated April 2022 Page 5 of 6 Engineer Option Permit Common Form LHD Reference: PART 3: Authorization to Operate(ATO) Except for date received,the Section below Is to be completed by the Owner or the PE. LHD USE ONLY: Initial submittal of request for ATO received: by Dote initials Date of Post-construction Conference; Post-construction Conference waived in accordance with G.S.130A-336.1(j): T he 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 the information in G.S.130A-336.1(k)(1)and 15A NCAC 18A.1971(f) ❑Yes ❑No 2. Operation and management program and ORC contract,if applicable ❑Yes ❑No 3. Fee (as applicable) ❑Yes ❑ No 4. Notarized letter documenting Owner's acceptance of the system from the PE ❑Yes ❑No 5. Owner meets requirements of ownership or control of the system per 15A NCAC 18A.1938(j) ❑Yes ❑No 6. Easement,right of way,or encroachment agreement required per 15A NCAC 18A.1938(j) ❑Yes ❑No 7. Multi-party agreements required,as applicable,pursuant to 15A NCAC 18A. .1937(h) ❑Yes ❑No If yes,agreements filed in County Register of Deeds in Deed Book Page Attestation by the Owner or the PE for Authorization to Operate I, hereby attest that all items indicated above have been provided to the Print name of Owner or Professional Engineer 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). Signature of Owner or Professional Engineer Dote 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 EOP- 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 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-336.1(m). A copy of this complete NOI/ATO with tracking information was sent to the State on via - Dote Email,FAX,USPS,Hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Dote 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—EOP COMMON FORM Updated April 2022 Page 6 of 6 PRELIMINARY SOIL AND SITE EVALUATION 3735 Shank Tipps Road Lawndale, NC 28090 Prepared For: Carolina Septic Systems, PC PO Box 26072 Charlotte,NC 28221 Prepared By: Thompson $1911; EnYironments Con suiting WATER • WASTEWATER • WETLANDS Thompson Environmental Consulting, Inc. PO Box 541 Midland,NC 28107 May 15, 2023 � tD SOIL SC/� 0 'IHO�gp 1287 qt'AoRmosti l INTRODUCTION & SITE DESCRIPTION This Soil and Site Evaluation was performed a 1.02 acre lot located at 3735 Shank Tipps Road, Lawndale, North Carolina (Catawba County Parcel: 265701068119). Thompson Environmental Consulting, Inc. (TEC)was retained to determine whether the soils were suitable for onsite subsurface wastewater treatment and disposal. The property was evaluated in accordance with North Carolina statutes for waste disposal ("Laws and Rules for Sewage Treatment and Disposal Systems", amended April 1, 2017). INVESTIGATION METHODOLOGY & SITE PHYSICAL CHARACTERISTICS Individual soil borings were evaluated, and soil color was determined with a Munsell Soil Color Chart. Observations of the landscape (slope, drainage patterns, etc.)as well as soil properties (depth, texture, structure, seasonal wetness, restrictive horizons, etc.) were recorded. The property has been previously developed with a single-family residence. Undisturbed areas are vegetated with mixed deciduous trees. FINDINGS A field survey was conducted on May 8, 2023. Three soil borings were advanced within the project study area and locations noted in the attached Figure 1. All borings were rated as Provisionally Suitable for the installation of a subsurface wastewater treatment and disposal system utilizing Accepted System and Prefabricated Permeable Block Panel System drainfield products and are denoted in the attached Figure as green points. Surfaces, when present,typically exhibited friable sandy loam to loam textures with weak, medium, granular structure 12 to 15 inches in depth. Upper subsurface horizons exhibited firm clay textures with moderate, medium, subangular blocky structure to a depth of 34 to 42 inches. A long-term acceptance rate (LTAR) of 0.3 gal./day/sq. ft. would be recommended for these soils. DISCUSSION The soils observed within the project study area will support the installation of a subsurface wastewater treatment and disposal system utilizing Accepted System or Prefabricated Permeable Block Panel System drainfield products. It is estimated that 6,600 square feet of suitable soil area would need to be allocated and left completely available for the installation and required repair area for an Accepted System serving a 4-bedroom single family residence. The required drainfield area can be reduced by 25% if using the Prefabricated Permeable Block Panel System. 3735 Shank Tipps Road 1 May 15, 2023 Preliminary Soil and Site Evaluation • � y CONCLUSION The findings presented herein represent TEC's professional opinion based on our Soil and Site Evaluation and knowledge of the current laws and rules governing on-site wastewater systems in North Carolina. Soils naturally change across a landscape and contain many inclusions. As such, attempts to quantify them are not always precise and exact. Due to this inherent variability of soils and the subjectivity when determining limiting factors, there is no guarantee that a regulating authority will agree with the findings of this report. 3735 Shank Tipps Road 2 May 15, 2023 Preliminary Soil and Site Evaluation {t Thomgfson Environmental Consulting,Inc. >{ et 1 P0 Box 541 PROPERTY ID#:fir 'O(cl 4L►kr I Midland,NC 28107 COUNTY: CO.-alAilOa SOIL/SITE EVALUATION f�(� for ON-SITE WASTEWATER SYSTEM OWNER: '1' 1 a i a')S ADDRESS: [ 1 a 13, �/f,,� DATE EVALUATED: S r P:i�;.ac. PROPOSED FACILITY: Ni PR POSED ESION FLOW(.194 `1 b V PROPERTY SIZE: t /.'O 3 LOCATION OF SITE: 1 S ,t.LL`j([�5 PROPERTY RECORDED: 1979 WATER SUPPLY; 0 Private 0 Public ❑Well ❑Spring Other EVALUATION METHOD: VAuuer Boring 0 Pit 0 Cut TYPE OF WASTEWATER: O'Sewage 0 Industrial Process 0 Mixed P • R SOIL MORPHOLOGY U OTHER P (.1941) PROFILE FACTORS t .1940 L LANDSCAPE HORIZON POSITION! DEPTH PROFILE # SLOPE% (IN.) .1942 .1941 .1941 SOIL .1943 .1,956 J944 CLASS STRUCTURE) CONSISTENCE! WETNESS/ SOIL SAPRO RESTR <AR TEXTURE MINERALOGY COLOR DEPTH CLASS HORIZ , o-3,f , -.4:-A.i, -6 sT ; , +_ . .4. - 1 U_ 15—kkAr nos* •, . e2 u? 9 ^, U • t `} • 4 ^ ::. DESCRIPTION INITIAL SYSTEM REPAIR SYSTEM OTHER FACTORS(.1946): Available Space(.1945) t, ,� SITE CLASSIFICATION](.1948): Provision ► ,finSystetnType(a) �.iCd 'Lr,��w �l EVAL[JA1�D BY:�l�G} titfPie:;1410:itia."W OTHERS)PRESENT: Ira 1 o --;-1741`4.:. .L?1�•.A - Site LTAR Q l 27 0.3 L. Thompson, LSS '�' .rf 11 �-2'1 COMMENTS; i '1rt,K... 1,.J r(Gst{..d asm� TA t- S(G , 14 a ,.[itt ,. `, t 4i fl :f Updated February 2014 O Y'"13, lace - fza� g`^baltt C I s il r C MU O a N N Qt Q Z UU y EZ U o<° �CO o 4:4 c co N Y f co c Ne d (�N o co C l 0_ CO m 3 w Q N .a - -a (6 � y.� Eau U co i c7 m w i /// 0. /'/ / . 1:1 / O M S / i o Al' 1 S M/ '2� • I o Q1 N z to Q = N W d T O C N 0 ILI i C O T J CO CO O O u0 0 J N H O I- c O 1 i a 8 m ....+...r r ..r Ivwrrw. lw,l.• pus rw�a. •w'ui.. • I' AS ....rI.*••••• OIMo1ri sam tam M.M •.•• \I I • id, /1i 1: ‘.. • 40, p.,A 1a110.t41 •i : 1 I pF •.44,114 .10 1'C rn[.•.NO..h'NI 00 n...0.OkIola r.1m .N I O.rw itaa P•et mMni+0+v roOwok coon• (YIYw N1r•.. 1•��l.�M r• •wIM11M...•..1•• .... .a.......M.I. r.Ml1.6l.r .N•.=.I W W..IM 1 MOIr. aN111n•W/l.gIWlNptoN.O A'•' W .bnaW.ram.1 n+••• • !✓.a ....1 11...11.....N.. .lwww.wM...0 r o.row W_.i.1/ll M,.Y...Y.IIIQ,a yl i . W▪M*w4lN.mu. wnl"'-'"i xrnxn .. C....,V...Da. .141.11441011:;MA''''' O. 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Nu,..., 1l•. ---' 6.c4.Nn.w.r 14.e1C..I0 . • .Pqql. �.E.e.�� .rwr..kM raill.n N \ 111,,1 1 •...re1'"••r'•'1.1•PMr.•. =7.rev 14m1 eao•LM P.•r II•cl 1`/ y' r: IIIMI WO1011 4•i1e1".MNr•N. _ r•�.tr.siN`r°j`nr--.wn�w.ww.+:w - � SM1.nM rd Mb.Mamie Wm, \ - Deed look TA hp70 ICI TOP ...... :. \\ • .err + ••....u..n enw memr.•. .. -o.r aW�r•.04 ... rr� ,s4tths Svw P..R ..00...M 1o.rmalwro ':yr,••y;c b r•At MwIfNM MIS SOMA q Dennis Hardin � '.; N"r.."r"`le a`0 Bandy Township,Catawba County.North Carolina Y0' ,....N..1+AQ Residential Subsurface Wastewater Treatment and Disposal System Engineered Option Permit for 3735 Shank Tipps Road Catawba County, NC Catawba County Tax Parcel: 265701068119 June 21, 2023 Prepared for: 0p so11 sc� G �HOM,o ,y JA so .r,, Clayton Homes of Conover 1/ '* 1 �,ii , 1230 Conover Blvd. W ��4j ', • Conover, North Carolina 28613 - '' / % 128) ckApeivt Prepared by: Carolina Septic Systems, PC Thompson Environmental Consulting, Inc. ,••0.0% CAR° .......... (/ •. George Barrier, PE 2� 0• ESSio•'•,y9 Larry Thompson, NCEHS, NCLSS = 44 ' tion!,) r '71* • .,••9GF o P4•.,r .."'•••••" JUN23 37,35 Shank Tipps Road Details Clayton Homes has contracted with Carolina Septic Systems, PC(CSS)and Thompson Environmental Consulting, Inc. (TEC)to develop a residential on-site wastewater treatment and disposal system expansion for an existing 4-bedroom home located on 3735 Shank Tipps Road Catawba County,NC(Catawba County Tax Parcel: 265701068119). The residence will be served by a private well. Based upon a soils investigation performed by TEC it was determined that a sufficient amount of "Suitable"Group IV soils is available on this property for the installation of a Pump-To Accepted System for both the initial system as well as the proposed repair system. CSS and TEC propose a design based upon 480 gallons per day flow at a 0.3 GPD/sq/ft long term acceptance rate(LIAR) for the soils. CSS and TEC would like to request that the following design performed pursuant to 15A NCAC 18a.1971 be approved for permitting under NC General Statute 130A-336.1 (Engineered Option Permit). Location From the 1-40/SR-1124(Old Shelby Road and Jacob Forks Road)interchange in Long View,NC, take SR-1124 south 15-miles. Turn left onto and travel south 1-mile on US HWY-I 8,then turning right and traveling 1-mile on SR-1101 (Roger Hill Road)then left onto SR-1100(Pea Ridge Road) 0.5-miles. Tun Right onto Shank Tipps Road and the site will be 0.25-miles north. References Laws and Rules for Sewage Treatment and Disposal Systems, 15A NCAC 18A, Section .1900, Department of Environment and Natural Resources, Division of Environmental Health, On-Site Wastewater Section, July 1, 2016. Innovative Wastewater System No. IWWS-1993-2-R13; North Carolina Department of Environment and Natural Resources, Division of Environmental Health, On-Site Wastewater Section, May 1, 2015. Primary Investigator's Credentials NC Registered Sanitarian No. 1208 NC Licensed Soil Scientist No. 1287 NC Authorized Onsite Wastewater Evaluator No. 10016E SC Professional Soil Classifier No. 111 Professional Wetland Scientist No. 1346 NC Subsurface Septic System Operator No. 22199 NC Grade IV Wastewater System Installer/Inspector No. 1762/17621 Primary Designer's Credentials NC Professional Engineer No. 019221 SC Registered Professional Engineer No.19378 VA Professional Engineer No. 0402054100 GA Professional Engineer No. PE042759 • • • 373,E Shank Tipps Road Plans and Specifications A. Septic Tank 1. The septic tank shall be State approved (Section .1953 of 15A NCAC 18A), watertight, structurally sound, and a minimum of 1,000 gallons in capacity. 2. The septic tank will be fitted with an approved effluent filter and riser for easy access and periodic maintenance. 3. It is the responsibility of the septic contractor to thoroughly inspect the septic tank prior to accepting delivery to assure that the tank has had time to properly cure and is free of cracks or other structural deficiencies. B. Pipes and Fittings 1. All discharge piping,connectors and supply lines should be made of SCH 40 PVC. 2. All joints must be properly"welded"utilizing the appropriate PVC cement for each application. C. Wastewater Distribution 1. A distribution box will be used to distribute effluent to individual drainlines. 2. The distribution shall be water tested, and adjusted as needed, to provide equal distribution to individual drainlines. D. Drainfield Installation 1. The drainfield has been previously laid out on-site utilizing metal stemmed flags. The property owner/builder should mark this area.and isolate it as much as possible from construction traffic. Prior to the system installation,the septic contractor shall contact the system designer for a preconstruction conference at which time the drainfield area will be re-verified. 2. Under no circumstances shall any construction take place within the drainfield area while the soil is in a wet condition. If the installer has doubts as to whether or not the drain field area is dry enough to begin construction,the system designer should be contacted for permission to proceed with the installation. 3. The specified system the shallow placed accepted wastewater system Infiltrator Quick4 Chamber System or other chambered systems with a 25% reduction approval granted by the state. 4. The drainfield consists of four(4) lateral trenches to be constructed 3-foot wide by 100-feet in length and placed 9-foot on centers. 5. The maximum trench depth for this system shall be 25 inches. 6. The laterals are to be installed on contour with the land, keeping the individual trench bottoms level from beginning to end. 7. The trenches should be left open for the final inspection by the system designer. E. Final Landscaping • 373,5 Shank Tipps Road 1. Final cover over the drainfield area shall be a minimum of 6 inches in depth. 2. The drainfield shall be shaped to shed rainwater and be free from low spots. 3. The drainfield area should be planted with grass as soon as possible to prevent erosion. The soil should be properly tilled, limed (if necessary)and fertilized prior to planting. After applying grass seed, the area should be heavily mulched with straw or other suitable material. F. Utility Conflicts 1. The owner and the building contractor must take special care in planning for water, power,gas,telephone and cable lines. These utilities shall be kept clear of all parts of the septic system and its proposed repair area. Improper planning for underground utilities can negatively impact the installation and, in some cases, cause irreparable damage and permit revocation. If there are any questions regarding preferred routes, contact the system designer as soon as possible. 2. Lawn irrigation should not be placed over the drainfield area. Maintenance G. Required Maintenance 1. The owner must maintain the drainfield area through periodic mowing. The drainfield must not be allowed to become overgrown. 2. The septic tank shall be pumped out when the solids within the septic tank amount to 25 percent of the inlet volume of the tank. 3. At each pump out, the septic tank effluent filter should be removed, and the accumulated debris washed back into the septic tank. Do not dispose of the filter debris onto the ground. 4. Any damp areas, leakages or malfunctions around the tanks or in the drainfield area should be addressed immediately by contacting the system designer. 5. Divert gutter downspouts and surface water runoff away from the septic and pump tanks. 373,5 Shank Tipps Road Design Specifics Daily Design Flow: 480 GPD Septic Tank Size: 1,000 Gallons(minimum) Effluent Loading Rate: Design=0.3 GPD per sq. ft. Drain Field Type: Accepted-25%Reduction Distribution Method: Distribution Box Number of Drainlines: 4 Drain Lines: (4)3-ft. Wide x 100-ft. Long Total Trench Length: 400 Linear Feet Maximum Trench Depth: 25 Inches Final Cover Requirement: 6 Inches Minimum Repair Option Effluent Loading Rate: Design=0.3 GPD per sq. ft. 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CJ1 n �yg '4 7UT*SOWfi.p P aRY 'A�F ° N N o o. iE Rio .�(`, \ i'4 � 1 ' � i . m , $ I in 5 -5-1' i 51.0 `-• AIM, '. At \ - A4.`-; 1111., 1 4 i ',. cm e W3 I cr -.kV\ \,.., ,,/ ...." \ :, vl i ?_1,..,. \ 1.5,,, , ___ T, ‘ 2-7.2— \'' -(4" ; • ..11 --., 13 o 23 (n 7 8 I z S2 d ("$ .Pn . I st•f1A1 �J I 'O g. a o m }.'i CI N Z 3 ��.. a. � 14 0. ; I ; i11 !? CD O. v1oi .a .,==-Ai F a ,fir n m p D h N cEr co a ? !"" w 4. a. r il $ m a o a p p p O w E* a o wra I T ,�-L4- D 1v d o i. m i Ox - a 0 O§ D IDm m 3 o v Q a co64 co in EF v c N •••• . I1•I,••••• ' o ro CON • oo �'1 CA n •, CO3 i l m w j i !PI7%�%% e1 • i O Y w iv G) IV�jy•�� •�� > a°�R n Z CO z a L` I — Pr CO pl 7 n-a (� .'• _bra 1 o 3 .i � ;•, ` bibY; r�� N N Z I i Qi__/ s CI Lo i 9_ INS i 1.,. �1 ii to a 0) ii. i--,%4, r i R -< w r, i . n14 a 7 H Ld . 5 fll a!1 i bii. i m W N 3 W v n a a a a f m a N Z 7 3 m a CI11 PIw co — : a m ' 8 A I° m o a M 1 a 2 2 —YID 1 a F. D $ m Zp m r '13 r 4 a € e �i01 —... E3 �n W>> W cn qT TZ a a �O —i0as',IN.. zr o w— W O 9 r- W Z l _.O m a O o �--i01 D—:.. v f m 1.40. - C1 ;s rio i--..'- . v f o ;���NP4 _ �io� a—:.. �� 0 3 ,-/7E4Iiiiii '' 3 0 . i' b- itail': a E On i.rill'( 1 \ tail': a, JP .1.. W30.4‘77.00107M0O717S7.N.7. I$ i1 ❑ o [ i '1 coC CO o Z co • • Q p0 ❑ ' 9=1►= A 0 � C s. AA. i . , + ..o : U, N c, •• 9..▪• F c C CO: z.tiR , • • IV 03 Za. o L 1 • ACORD CERTIFICATE OF LIABILITY INSURANCE DATEf2M/DDr YI 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 Higginbotham Insurance Agency, Inc. PHONE David Vaughan FAX 500 W. 13th Street rA/c,No..ExxtL'9187797880 (NC.No):817-882-9284 Fort Worth TX 76102 ADDRESS: 99� r dlv1 @ hi inbotham.net INSURER(S)AFFORDING COVERAGE NAIC# License#:2081754 INSURER A:Mid-Continent Casualty Company 23418 INSURED CAROSEP-01 INSURER B Carolina Septic Systems, PC 3901 Davis Lane INSURER C: Charlotte NC 28269 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:484602894 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. ILNSR TR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER (MM/DO/YYYY) IMM/DD POLICY EFF IYYPY1 LIMITS A X COMMERCIAL GENERAL LIABILITY 04-GL-001085517 9/1/2022 9/1/2023 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $100,000 X Professional MED EXP(Any one person) $Excluded PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $3,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per $ AUTOS ONLY AUTOS ( accident) HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? n N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 ACCORDANCE WITH THE POLICY PROVISIONS. For Informational Purposes Only AUTHORIZED REPRESENTATIVE 94'Cl44g ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACCPRCI CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) _ 9/7/2022 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 Higginbotham Insurance Agency, Inc. NAME: David Vaughan 99� PHONE FAX 500 W. 13th Street .(ALG,No.Eat): 9187797880 INC,No):817-882-9284 Fort Worth TX 76102 E-MAIL divjr@higginbotham.net INSURER(S)AFFORDING COVERAGE NAIC# License#:2081754 INSURER A:Mid-Continent Casualty Company 23418 INSURED THOMENV-01 INSURER B:Hartford Underwriters Insurance Company 30104 Thompson Environmental Consulting, Inc. PO Box 541 INSURER C: Midland NC 28107-0541 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1600075032 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. IL7R TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP !NM WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 04-GL-001086672 9/25/2022 9/25/2023 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $100,000 X Professional MED EXP(Any one person) $Excluded PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 X POLICY JECOT- LOC PRODUCTS-COMP/OP AGG $3,000,000 OTHER: _ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per $ AUTOS ONLY AUTOS accident) HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB — OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION 38WECNW6175 10/17/2021 10/17/2022 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? n N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 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 ACCORDANCE WITH THE POLICY PROVISIONS. For Informational Purposes AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ______...-...1 LAGOVIS-01 JROBBINS A�oR® CERTIFICATE OF LIABILITY INSURANCE DATE/7iar2o2 ) 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 NAME CT Robbins&Associates Insurance Agency,Inc. BAH"Jc°°,No,EXt):(704)226-1300 NC,No):(704)226-1320 PO Box 1458 E MgqIL Monroe,NC 28111 ADDRESS:cents@robbinsandassociates.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Erie Insurance Exchange 26271 INSURED INSURER B: Lago Vista Landscaping INSURER C: ' Manuel Rocha 2517 Pageland Highway INSURER D: Monroe,NC 28112 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 I TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DD/YYYY) (MMJDDIYYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR Q26-0521176 2/5/2023 2/5/2024 pREM SES(Ea occu o nce) $ 1,000,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY j : LOC PRODUCTS-COMP/OP AGO $ 2,000,000 I OTHER: $ AUTOMOBILE LIABILITY (COMBINED aaB ident)SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSRE� ONLY AUTOSp Ep BODILYOq INJURY(Per accident) $ AUTOS ONLY AUTOS ONLY O'er accldent?AMAGE $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ —~EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION X STATUTE OTH AND EMPLOYERS'LIABILITY ER Q89-3000667 5/30/2023 5/30/2024 100,000 AOFFICERIMEMBER EXCLUDED?ECUTIVE N J A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500 000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ ' DESCRIPTION OF OPERATIONS I LOCATIONS I 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 Carolina Septic Systems,PC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P Y ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 26072 Charlotte,NC 28269 AUTHORIZED REPRESENTATIVE� ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AtigErie CERTIFICATE OF INSURANCE Insurance( •• , -THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY- 100 Erie Ins PI Ene.PA 16530 CERTIFICATE HOLDER COPY NAME AND NUMBER OF AGENCY DATE ISSUED ROBBINS & ASSOCS INS ACV INC JJ4299 04/25/2022 500 N CHURCH ST NAME AND ADDRESS OF CERTIFICATE HOLDER MONROE , NC 28112-4808 704-226-1 300 NAME AND ADDRESS OF NAMED INSURED THOMPSON ENVIRONMENTAL LAGO VISTA LAWNCARE & CONSULTING INC LANDSCAPING SERVICE LLC * PO BOX 541 2602 GOLDMINE RD MIDLAND NC 28107- MONROE NC 28110-8947 This Is to certify that policies,as Indicated by Policy Number below,are in force for the Named Insured at the time that the certificate is being issued. POLICY' —�-POLICY TYPE OF INSURANCE POLICY NUMBER LIMITS OF INSURANCE EFFECTIVE RATE. EXP/RATION DATE _ GENERAL LIABILITY Q260521176 02/05/2022 02/05/2023 EACH OCCURRENCE s 1000000 COMMERCIAL GENERAL LIABILITY OCCURRENCE FORM GEN'LAGGREGATE LIMIT APPLIES FIRE DAMAGE S � PER:PROJECT (Any one premises) 1000000 MED EXP fAny one person) S 5000 * �sr y✓ PERSONAL G ADV INJURY S 1000000 • .Y21 GENERAL AGGREGATE S -`''�v4�h 2000000 PRODUCTS-COMPIOP AGG S } 2000000 1 • BODILY INJURY S -- - ------ -- (EACH PERSON) BODILY INJURY (EACH ACCIDENT) PROPERTY DAMAGE S BODILY INJURY AND PROPERTY DAMAGE COMBINED ) • EACH OCCURRENCE AGGREGATE WORKERS COMPENSATION Q893000667 05/30/2022 05/30/2023 STATUTORY AND BODILY ACCIDENT S 1 00000 EACH ACCIDENT EMPLOYERS LIABILITY INJURY DISEASE S 500000 POLICY LIMIT BY DISEASE S 100000 EACH EMPLOYEE DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CANCELLATION:SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. IMPORTANT:It the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions o1 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). THIS CERTIFICATE IS ISSUED FOR INFORMATION PURPOSES ONLY AND ERIE INSURANCE CONFERS NO RIGHTS ON THE CERTIFICATE HOLDER.IT DOES NOT AFFIRMATIVELY OR NEGATIVELY LIST,AMEND,EXTEND OR OTHERWISE ALTER THE TERMS,EXCLUSIONS AND CONDITIONS OF INSURANCE COVERAGE CONTAINED IN THE POLICY(IES)INDICATED ABOVE.THE TERMS SEE REVERSE SIDE AND CONDITIONS OF THE POLICY(IES)GOVERN THE INSURANCE COVERAGE AS APPLIED TO ANY GIVEN SITUATION.LIMITS SHOWN MAY HAVE BEEN REDUCED BY CLAIMS PAID.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER AND CERTIFICATE HOLDER. AUTHORIZED REPRESENTATIVE UF-158E 09112 CIF _ _