NC0030996_Final Permit (non-discharge)_20201022

DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
Roy cool'tat MANDY COFIEN, NID, MP1-1
GOVt'R\OR SGCRFi'1'Ait}'
DANI1?t. STAuw
Dutr ,roit
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 N01 received: by
Date Initials
PART 1: Notice of.Intent to Construct (NOI)
❑ New ® Expansion
❑ Repair —LHD Permit Number ❑Repair —EOP Permit Number
1. Facility Owner's name: (Owner, Company Name, Utility, Partnership, Individual,'etc.):
Jen-Nel Properties, Inc.
Mailing address: P.O. Box 399 city: Little SwitzerlandState: NC Zip: 28749
Telephone number: 828-467-0629 E-mail Address: [e-mail]
2. Professional Engineer (PE) name: _ Mark Brooks License number- ^026539
Mailing address:17 Arlington Street City: Asheville srate: NC zini 28801
Telephone number: 828-232-4700 _ E-mail Address:._ mbrooks@.brooksea.com_
3. Licensed Soil Scientist (LSS) name: Steve Melin License number: 1254
Mailing address: 15 Lone Coyote Ridge city: Fletcher 4ztate. NC ,,ip: _ 28732
Telephone number: 828-551-9903 _ E-mail Address: _ simeli (�omail.com
4. Licensed Geologist (LG) (if applicable) name:
Mailing address:
City:
Telephone number: E-mail Address:
License Number:
State: Zip: .
5. 'On -site wastewater Contractor nameWater Management - S. Gask'Mnse number: 1077
Mailing address: 4744 Celia Road city: Lenoir State: NC zip: 28645
Telephone number: 828-244-9765 E-mail Address: [e-mail] _
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 M LSS ❑ LG ® On -site Wastewater Contractor
WNVW.NC1)l1I1S:G0V
TI.L 919-707-5874 - FAX [phone]
LOCATION: 5605 SLY FORKS.Ri) • R.ALE IGI1,NC 27609
MAILING ADDRESS: 1642 MAIL SERVICE CrNTER ". RALEIGH, NC 27699-1642
AN EQUw. OPNORTUNITY / AITIRNIATIVr ACTION GNI'1_nY1-R

State of NC EdP;
LHD Refermce.,
7. PropertV 16-6-at'I n'(Ohysialad'dress,'"ax-parcel identification *number osubdivision Jot, block number
of the
86 High'Aidge* Road :(PIN 1� 078 7-48� -130 3)
property to'be'Permitted):
MbDoWell
County Name.,
.8. Type of facility: ❑ Place of residence !Nci. c. 6e8. r I ooms: I . No. Occupants
0 pd/seatat rest:; d/b r,'60
t 25 gp
Place of bwiness' Basis for fi 6w,calcula,tion: 9
.. I gpdlroom; uQ;,WM7aMFF
❑ Plaice"Of pu'blIc'assembly .' 'Ba'sisfar flomi calculation:
c a oUld affect the wastewater load: I High ,9. 'Oa iors th� t w h:st*!9­t,h ".R6s'taOrant
* ' 6 W io.-, Typd, location- , an'dcI8ssific'a_tIdri'(p' rk,61e.A961),of 6stewatetsystem`
,T%It�6 \/ Ohicf6M. i_CZOc�ioi-n Inr-nfi�M nc� Qh6vuh nn nr-nr)Mh nvihrj, niqnq
11. Design Wastewater flow: IT,040 god (FqrfloO>3;0010 godobdindustriolpr6c6s, qopllcqt& p1m sjtollbqsent to thdSto&.]
be . sig n tvasiewate,r' iriin Ii ❑A6 tie � 0 High strength Ellicibsteia*1
gi met n I process
12. A platas defined inG.S. 130A. 3A7P) is attached: "0 Yes ❑ No
n. bwn&meets�eeOuiremdnfs of ownershi 'or cohtr.61:6f the system per i5A NCAC 18A 11938(j):"Yes ❑ No
,14: Easement, (lot o . f way or encroachmen . t - agreement required . pee.1 . 5A NtAt. 18A.'59*& 'O-Yes fXjr No
If yes, 'd.6c-umeht6ti.6n filed in. ..County Register, of De6ds'ln.beed book' Page
i6qiuire'd,_ a-si.apblicable",ptfesivaint to' 15A NCAC i8A,A937(h):: �es No
S., Multi -party agreementsQ
jf yes, agreements filed in .'County Register of (Deeds in 6eed,book.,Page
Lobtldh Of, proposed or existing wells (driO kirfg Wa terIrrigation, geothermal, groundwater monitoring,
n n d plans saiifollr�g'j etc.) and any;potable' and: 6 -pbtabie` water conveyance ines,is indicate on,atfiachdid'01`6 and'.
complies,wit1115A I46C 1,8A . 19'56: Z]:Y I es F-I No
ThIs1s'a saorolite system,. ❑ Yes 0 No
A7. Evaluation(s)ofoicon itions an sit
e -features in accordance With 6.8., I3OA-335(al).4tned and sealdd.bya
tss Is, attached 91 -Yes n No
18. E%ta1UatIon.of.g66I.pgIc'and` liydrdg6'olbgic.'tdriditions:sigii6d. and sealed ,byaW Isattached 'nYes, ff]NA-
49. Proposed landsicope,41ie, drainage, or soil modifications are iatiached: ❑ Yes NA,
Attest I atlov,:b y Prqftss . 16nai E . ngineer-1 . I . censedin North taro fina, pursuant to G.S. 89,C
jjereby attest .L'th f-theinfoeratibneeiui included with
Reglstef�d Professidnat Engine& (print Name)
. I .. 7 .. . . ' and
this Notice of Intent to'Construct Is accurate and complete to the my. kno%%;Iddge that the proposed
systemha ; 11 - meet
t apolica I b [&'federal,, . State, . �.and local . laws; regUlations,ru es n, din d I and ordinances in accordance with
Oso 180Ar -.1(9)
Signature of, Licensed Proiess, ot i a Engineer Dole
'Page 2 of 6
0 H_: HS/EHSIOS WPB,--: t6MOON FORia elteetive june, -j" w!

State of NC EOP
UiD Reference:
This "section is for Owner use to either designate PE as their legal representative or to self -submit the Not.
Designation of Registered Professional Engineer as legal representative of Owner for this Notice of intent:
I, VR i-1 :3-en hereby designate
Print Name of tIvnei Print Name of Registered Prolessiono naineer
as my legal re resent live for purposes of this Notice of Intent pursuant to G S.130A-336.1.
signature of owner Date
Ownersey-submittal of NOi:
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 have no liability
for wastewater systems designed, constructed and installed pursuant to on Engineered Option Permit. [(NC General
Statute 130A 336.1(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 LHO deems that the Notice of Intent to'Construct is complete via
signature in the section above, 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.
Page 3 of 6
DHHS/EMS/OSWPB - COMMON FORM Effective June 1, 2018

�51: ate Of NC t OP
LkD Reference,
'This section fi6i Local Healtlibqparttrie it. u'se only.
PART 2: LHD CoinOldtdrkss Review of the 'Notice of lhf6it 6 edniiruct
k(c) Completeness Review for Notice of Intent to Constiuct. —'The'16cal hikildi tiepartntent slit ll d6ierinini? whethera_ 'notice! of
.intent.to construct; a5'requiredjoursuant subsictian'(b).ofthis seetion, is corripliie ivith/h 151ibihi&ss ddysafter the local health
opartmentreeet'ves,th-enotice d'fitit'ent-toc6r*)stiuct. Adetertriinatiotiolcon)pletei)essnieatistildtthe�.'n6i!ci?ofii)ten.t.to
construct i , nk�lfjdes ap ll pfthe required components. 1philocow"he6widel department determines' that M6 notice , Of I intent . to
constructs incopyolere, the department shall'hodjy thebwndrorthe grbjess1Qh61 en#ifidet of the coinp.'bnentsbeeded to
complete the notice 7heoiVner6ior6pssional indt10 h'idii)t.depdtttreit'lo-cjrletie
qef!d&ie1:es in tine notice. The determination as to whether the nvtice.of intent to'
ment-r-eceives , t e a , ddition . a it a Jon
construct is complete tviihin 10 business do after .the de rt I 1 6- from the otivner or
1form
-pr6f6ii6ndlengtheer. ff theWepartniefiffidils to act this subsection, the
"engineer nioy treat the failure to act as a determination of completeness,"
7L Notice
The review for completeness of this 0 fl1ce of iiiientwas ',conducted 'in accordance with -G'.S'. 136A 386.10.. ''This
NOI- is determined to bb:
INCOMPLETE (it box is.6eckedl_ Inforrinaition'In this sect'ion is.required.)
Blasedupon review of informatioilsubmitted bylhe.PE in Part 1, the UIM�ihgltemare missing:
.Copidt.df'Ibis' fdrr'h:listi'hg:missing k6ms`werlisent t6the designP'Eand the Ow
ner on
b IS, US
Via With:dirediiins'to re-su se -submit m sing s frig Page .5�of this form..-
.priht kanic ofAuthoriiedAgent of the LHD Si4tidiure of Authbrked A - ge11 �t of theL111) Dawi
COMPLETE (If 6cix"i-sche,c'ked,:informati'on in,t'hissettion.is e0qul . redl
t6s d upon review of information su bn!I Red by1he: P. EArPtift lof-this f6en�-thi§ NOI isdeemed COMPLETE.
:Copies of.this,§igned form were sent to the design -PE and theOvjh.&,66 Ewli
1Dqt.e 'Email, "X, U10S, hofid, deliver&
t'.
,A-c6py,of this NOI.'and irkkihginformation mia's-Serit ohe State 'on 6;via ErY 6;1
Dole. 'Einail.;:FAX,USPISI)iutid-delivered
n Ow m
the 010 vote
P.396 4'6f 6
DH14Sffi1SjbSWPB — % COMMON FORM Effective June 4,,,2018

State of NC EOP
LHD Reference:
PART 3: Authorization to Operate (ATO)
Except for date received, the Section below is to be completed by the Owner or by the PE designated to act as theirlegal representative for
the EDP.
LHD USE ONLY: initial submittal of request for ATO received: by
Date Initials
Date of Post -construction Conference:
The 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:
a. Signed and sealed evaluation of soil conditions and site features
Des
❑ No,
b. Drawings, specifications; plans
®� �Y
❑ No
c. Reports on special inspections and final inspection
ICY S
❑ No
d. Management Program manual
v�s
❑ No
e. On -site Wastewater Contractor's signed statement
Y s
!frY'
❑ No
f.. Signed and sealed statement pursuant to 15A NCAC 18A .1938(h)es
❑ No,
2. Fee (as applicable)
❑ Y
ON 0
3. Notarized letter documenting Owner's acceptance of the system from the PE
es
❑ No
Attestation by the Owner or the PE for Authorization to Operate
&IY,21J
1, f /l_ 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 lbws,
regulatio s, rules a d ord' pees ' accordance with G.S.130A-336-.1(e)(6).
%d
Signature of Owner or Professional Engineer Date
This section for LHD Use Only.
LHD Review of required information for the ATO
❑ INCOMPLETE
Based upon review of information submitted by the Owner or PE 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, FAY, LISPS, Nand -delivered
P nt name of outhorized Agent of the LHD Signature of authorized Agent of the LHD Dote
COMPLETE
Based upon review of information submitted by the Owner or PE in the Section above, this Authorization to
Operate is hereby issued in accordance with G.S. 13.OA 336.1(m).
A copy of this complete N01/ATO with tracking information was sen to the State on c) Q via
(� Date Email, FAX USPS lia+td•rlelivered
Xr 1 5 RVn.) - �s � :r 'N HS IA15
Print =74 of authorized Agent of the LHD Signature oftt! torized Agent of the LHD Date
ISSUANCE OF.CERTiFICATE OF OCCUPANCY: Once the LHD determines completeness based upon the PE 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.5.130A-339.
Page 6of6
DHHS/ENS/0SWP8 — COMMON FORM Effective June 1, 2018