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Home My WebLink AboutWELL-08-2023-201836.TIF catawba county public health VOLUNTARY RELINQUISHMENT OF ADMINISTRATIVE APPEAL RIGHTS Date prepared: 8/18/2023 Owner(s): Ronald Chapman Mailing Address: 2322 Moss Farm Rd Hickory,NC 28602 Property location/site legal description: 2322 Moss Farm Rd,Hickory PIN: 279110467724 Well PermitWELL-08-2023-201836 Date Issued: 8/4/2023 I, ZoiJA(d LLzeoaitwod 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)in order for the authorized agent/local health department to issue the applicable permit(Well permit)for the site. I understand by completing this form that the permit(s)for a New Well (well permit type) 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 Well Permit that the current Well Permit must be revoked. I understand that the local health department's revocation of the Well Permit 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 I do not have to wait 30 days for the revocation of the permit to take effect. Signature of Property Owner: �^ Date Signed: 9'/S - 3 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. ( ) catawba county public health August 18, 2023 Ronald Chapman 2322 Moss Farm Rd Hickory, NC 28602 Subject: Notice of Intent to REVOKE the Well Permit for 2322 Moss Farm Rd, Hickory PIN 279110467724 Catawba County Permit: WELL-08-2023-201836 Dear Mr. Chapman: The Environmental Health Division of Catawba County Public Health intends to revoke your Well Permit 30 days from the date of this notice. If the permit is revoked,you must apply for a new Well Permit and meet the requirements of the current laws and rules necessary to obtain a new Well Permit. 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 Specialist.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 htt0://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 150E-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 [ciuwho County Government Center 25 Government Drive PO Box 389 Newton NC 28658 828 465.8270 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 8/18/2023. 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, 4—Ufinke Blake Perkins, REHS Environmental Health Specialist Catawba County Public Health • CATAWBA COUNTY - _ Public Health Department Subdivision +,., I Environmental Health Division PINt 279110467724 `� PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 2 Site Address: 2322 MOSS FARM RD, HICKORY NC 28602 Name on Permit: RONALD CHAPMAN Property Size: Acres 11.28 Directions: Right 127, North on moss Farm RD,Access to the property is by a paved 25" deeded ROW off of Moss Farm RD,going to an adjoining with 2314 Moss Farm RD Owner/Authorized Representative Acknowledgement of Permit Receipt XI certify that I am the owner or authorized agent(owner's authorization required)representing the owner of the property described above. XAs the property owner or authorized representative, 1 have received the above referenced permit(s)as requested in the application for service RBPR-06-2023-44756,by the following method(s): Received in Person Facsimile Transmittal (Return form with signature required) 7- Electronic Image Transmittal/ E-mail (Return receipt required) �f As the property owner or authorized representative I have reviewed and understand the specific conditions r�l 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: 08/04/2023 Owner/Authorized Representative Signature '' j Date Documentation of Permit(s)Transmittal (permit transmitted by electronic or other means) Permit transmitted by [' (name ofperson sending permit) Signature L Date/Time. S'i14✓3 Method: Fax ,/ 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 youPlease ttake a few momentts tto complette our custtomer service survey att http://www.surveymonkey.com/s/EHCusttomerService drew. ChaprhaA Dogma, Con ehpennit 08/042023 13:41