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211 <br /> 0,c sTnrf o <br /> of ROY COOPER• Governor <br /> � <br /> NC DEPARTMENT OF KODYH. KINSLEY• Secretary <br /> '�� HEALTH AND y 1 HUMAN SERVICES HELEN WOLSTENHOLME • Interim Deputy Secretary for Health <br /> � ' _ a <br /> ♦,�QUAH N�ERY MARK T. BENTON •Assistant Secretary for Public Health <br /> Division of Public Health <br /> COMMON FORM FOR ENGINEERED OPTION PERMIT <br /> See Instructions for Use in Appendix A <br /> Except for"Date received",this Section to be completed by the Professional Engineer licensed in accordance with G.S.89C <br /> LHD USE ONLY: Initial submittal of this NOI received: 12/13/2022 by kgh <br /> Date Initials <br /> PART 1:Notice of Intent to Construct(NOI)-Please check all that apply <br /> ❑X Single System or ❑ Multiple Systems <br /> AND <br /> ❑X New ❑ Expansion ❑ Relocation of all or part of the Existing System ❑ Relocation of Repair Area <br /> ❑ Repair—LHD Permit Number ❑ Repair—EOP/LSS COVID 19/AOWE Permit Number <br /> 1. Facility Owner's name: (Owner, Company Name, Utility, Partnership, Individual, etc.): <br /> VERNON DAVIS <br /> Mailingaddress: 2401 NC HWY 54 WEST City: CHAPEL HILL State: NC Zip: 27516 <br /> Telephone number: 919-459-2603 E-mail Address: ADAVIS@VANGUARDPG.COM <br /> 2. Professional Engineer(PE) name: ATHAN M PARKER, PE License number: 43250 <br /> Mailingaddress: PO BOX 4580 City: EMERALD ISLE State: NC Zip: 28594 <br /> Telephone number: 919-795-9594 E-mail Address: ATHAN.PARKER@ AMP DENGINEERING.COM <br /> 3. Licensed Soil Scientist(LSS) name: HAYWOOD PITTMAN, LSS License number: 1262 <br /> Mailingaddress: 1073-1 GREGORY FORK RD City: RICHLANDS State: NC Zip: 28574 <br /> Telephone number: 910-324-2892 E-mail Address: PITTMANSOIL@YAHOO.COM <br /> 4. Licensed Geologist(LG) (if applicable) name: License number: <br /> Mailing address: City: State: Zip: <br /> Telephone number: E-mail Address: <br /> 5. On-Site Wastewater Contractor name: HAYWOOD PITTMAN, LSS License number: 3825 <br /> Mailingaddress: 1073-1 GREGORY FORK RD City: RICHLANDS State: NC Zip:28574 <br /> Telephone number: 910-324-2892 E-mail Address: PITTMANSOIL@YAHOO.COM <br /> 6. Proof of Errors and Omissions or other appropriate liability insurance for the following persons is attached <br /> that includes the name of the insurer, name of the insured and the effective dates of coverage: <br /> ❑X PE ❑X LSS ❑ LG X❑ On-site Wastewater Contractor <br /> NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH <br /> LOCATION:5605 Six Forks Road, Raleigh, INC 27609 <br /> MAILING ADDRESS:1642 Mail Service Center, Raleigh, NC 27699-1642 <br /> www.ncdhhs.gov • TEL:919-707-5874 • FAx:919-845-3972 <br /> AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER <br />