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HomeMy WebLinkAboutCBPR-07-2023-44846.tif RBPR-03-2023-43715 8422 Chick Dr Catawba,NC �/� a, ROY COOPER•Governor `�• : /N\ NC DEPARTMENT OP KODY H.KINSLEY•Secretary EDP-0-2023-192933 �� I .p HEALTH AND HELEN WOLSIENHOLME•interim Deputy Secretary for Health HUMAN SERVICES MARK T.BENTON•Assistant Secretary for Public Health Division of Public Health Adams 4 bedroom Home with Amenities-Wastewater System COMMON FORM FOR ENGINEERED OPTION PERMIT See instructions far Use In Appendix A Except for"bate received",this Section to be completed by the Professional Engineer lkrnsed In accordance with 6,S,89C LHD USE ONLY: Initial submittal of this NOI received: 1-1 i.{ 2_3 by fc-+ Mote tnJttats PART 1:Notice of Intent to Construct(N01)-Please check all that apply ®Single System or [ Multiple Systems Existing system is being abandoned and a com letety new system(or new uses is being tisstatted. ❑x New ❑Expansion ❑Relocation of ail or part of the Existing System ❑Relocation of Repair Area ❑ Repair-LHD Permit Number ❑Repair-EOP/LSS COYID 19/AOWE Permit Number 1. Facility Owner's name:(Owner,Company Name,Utility,Partnership,Individual,etc.):_ M&A Adams Family Limited Partnership(Alma Adams&Michael Adams) Mailing address: 315 N College Street City: McKinney .State; TX. Zip: 75069 Telephone number:(972)567.9385&(972)567-9146 E-mail Address: alisa_adamseatt.net&webadams@attnet 2. Professional Engineer(PE)name: Michael Lash,PE. License number: NC.#14265 Mailing address: 1104 Cindy Carr Drive City: Matthews State: NC. Zip: 28105 Telephone number: (704)847-3031 E-mail Address: mikel©Iashengineering.00m 3. Licensed Soil Scientist(LSS)name:Caroline J.Edwards License number:#1220 Mailing address: 991 Duncan Road City: Rutherford State: NC Zip:28139 Telephone number: (828)289 0122 E-mail Address: CJEdwards234©gmail.com 4. Licensed Geologist(LG)(if applicable)name: NIA ___ `License number: , Mailing address:— City: State: Zip: Telephone number: E-mail Address: 5. On-Site Wastewater Contractor name:Andrew Suttles License number: #1876 Mailing address: 2761 Harmony Grove Rd City: Nebo State: NC. Zip: 28761 Telephone number: (828)460-7404 _ E-mail Address: info@sutttesgrading.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 X❑LSS ❑ LG ®On-site Wastewater Contractor RECEIVED NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH LOCATION:5505 Six Forks Road,Raleigh,NC 27609 MAR ) 4 2023 MAILING ADDRESS:1642 Mali Service Center,Raleigh,NC 27699-1642 www.ncdhhs.gov • TEL:919-707-5874 • FAx:919-845-3972 AN EOUAL OPPORTUNITY I AFFIRMATIVE ACTION EMPLOYER Environmental Health GO CamScanner } EOP-04-2023-192933 Engineer Option Permit Common Form LHO Reference: -- 7. Property location(physical address,tax parcel identification number or subdivision lot,block number of the property to be permitted): 8422 Chick Dr.Catawba,NC.Tax#471003424026 County Name: Catawba a. Type of facility: Place of residence No.Bedrooms: 4 No,Occupants:7 Place of business Basis for flow calculation:4 bedroom house with amenities=720gpd Q Place of public assembly Basis for flow calculation: 9. Factors that would affect the wastewater load:Standard Residential Wastewater 10. Type and location of proposed wastewater system: Septic Tank to Pump tank to Pressure Manifold to T&.i Disposal-with reduction.Type Ill b.e. 11. Design wastewater flow: 720 gpd(For lbw,3,000 gad and industrial process,duplicate plans shall Or mot to the State.) Design wastewater strength: [X domestic [}high strength []industrial process 12. A plat as defined in G.S.130A-334(7a)is attached: (1 Yes 0 No 13. Location of proposed or existing wells(drinking water,irrigation,geothermal,groundwater monitoring. sampling,etc.)and any potable and non-potable water conveyance lines is indicated on attached plans and complies with 15A NCAC 11EA.1950: ®Yes []No This is a saprolite system. []Yes (J No 14, Evaluation(s)of soil conditions and site features in accordance with G.S.130A-335(a1)signed and sealed by a 1.55 Is attached: ®Yes ❑No 15. Evaluation of geologic and hydrogeologic conditions signed and sealed by a LG is attached ❑Yes XI NA 16. Proposed landscape,site,drainage,or soil modifications are attached: Q Yes 0 NA Attestation by Professional Engineer licensed in North Carolina pursuant to G.S.89C Michael Lash,PE. hereby attest that the information required to be included with Registered Professional£ngiaer,(Print Noma) this Notice of Intent to Construct is accurate and complete to the best of my knowledge and that the proposed system shall meet appiicabi ederal,State, nd local laws regulations,rules,and ordinances in accordance with G.S.130A•336-.1(e)(6)•/ AN), AWN S re of eared Pro xssonat i 7!Sate SEAL 14265 /Ø3 �rrhsrnita►�"' DNNs/EH5/OSwP—FOP COMMON FORM Updated February 2022 Page 2 of 6 CamScanner EOP-04-2023492933 Engineer Option Permit Common form LHO Reference: This section is for Owner we w Mther deshasete Pear tbek legal reptesenkraVe orearagetrbrrat the RIM Designation of Registered Phtlesslanal Engineer as legal representative of Owner for tile'Hate of Went: i 1l s hereby designate Wheel Leah,PE. PAW NameofOwner hint laseeeflegide l rattssbnelEngieer as my le ntative frpulooses of this Notice of Intent pursuant to G.S.13tJA-336.1. Siarkeure Whew Owner enfeubnriMml of NCR: I. hereby submit this NO prepared by ➢seer Nome a/OAmer hint Nave a/tkrnaedPLr pursuant to GS.130A-336.1. Ammer w Maw bate NOTES: LIABILITY; The Deportment;,the Department's authorized agents,or local hearth departments shah have no Nabi ltyr for wastewater systems designed,rorntructed,and installed pursuant to an Engineer Dptfan Permit XGS 130A- 33610 RIGHT OF ENTRY: The submittal of this Notice of intent to Canstntct prams right of entry to the Local Health Department and the State to the rem property. ISSUANCE OF BUILD:NO PERMIT: Once the CAD deems that the Notice of anent to Construct Is complete via signature in the section below,the owner may apply to the local permitting agency fora permit for ekKbital, plumbing,heating,air conditloningor other construction,location,orrrkcationocavitynullsanyprovisionof genera!or species!law pursuant to as.130A-338 j/EHAIDS WP -EOP COMMON FORM Updated February 2022 rage"1 et CamScanner EOP-04-2023-192933 Engineer Option Permit Common Form LHO 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 deportment shall determine whether a notice of intent to construct,as required pursuant subsection fbl of this section,is complete within 15 business days after the local health department receives the notice of intent to construct. A determinotion 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 department to cure the deficiencies in the notice. The local health department shall make o final determination es 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 pro/esslonal engineer. if the department foils to act within any time period set out in this subsection,the owner or professional engineer may treat the failure to act os 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: V INCOMPLETE(If box is checked,Information in this section is required.) Based upon review of information submitted in Part 1,the following items are missing: Copies of this form listing missing Items were sent to the design PE and the Owner on Date via with directions to re-submit missing items using Page S of this form. Fmolt FAX USPS,hand-delivered Print Name of Authorized Agent of the LHD Signature a/Authorized Agent of the tND 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 NOt is deemed COMPLETE. Copies of this signed form were sent to the design PE and the Owner on via t'n'*. • Date tmolt FAX.USeS,hand-delivered A copy of this NOt and tracking information was sent to the State on via Cate Email,FAX LISPS,hznd.d lherrd 12:144,A nity1/Jr__ -3-23 Print Name of Authotrzed Agent of the I HD Signature of Authorised Agent of the LHD Date DHHS/FH5/OSWP-FOP COMMON FORM Updated February 2022 Page 4 of 6 CamSeanfler I pPC) - -------- IO <----- �O� I \ tfl C� O OAP 90 ° P�Q G)\G ITO ELKIN 1_tx;a11�w. 1vp :'1;SLR. 1 - _ \V- 'N 0:• Ili ..................... - - --., • T&J PANEL \ ti 1 DISPOSAL \ REPAIR ok \ �� AREA AREA \ 4'4 0\ \\C %* . . . ., \\ \,-:4k SEPTIC AND .� \ 3 \ N `\ / •UMP TANK • 110111111 'a 14IJ� i { `\ ‘ •.( . 5 \ • ' \--- 4:o. ...0,0 \\'' - ' \, Aiiiii L _ I ADAMS 4 BEDROOM HOME with AMENITIES WASTEWATER FACILITY Wastewater Facllmes for: I M &A Adams Family Limited Partnership Adams 4 Bedroom Home A'Llsa Adams & Michael Adams 8422 Chi Dr. Cat 315 N College St Catawba, NC. I McKinney,TX 75069 Catawba County (972)567-9385 allsa_adornsCatt.net Tax Parcel ID.-4471003424026 (972)567-9146 webadamsoatt.net Scale: 1"=60' Date:3-9-2023 I