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139 <br /> CAEOP22-0013 <br /> Engineer Option Permit Common Form LHD Reference: <br /> 7. Property location (physical address,tax parcel identification number or subdivision lot, block number of the <br /> property to be permitted): 3026 WHITE CROSS RD; PIN: 9749402351 <br /> County Name: ORANGE <br /> 8. Type of facility: ❑ Place of residence No. Bedrooms: No. Occupants: <br /> X❑ Place of business Basis for flow calculation: DOLLAR GENERAL STORE <br /> ❑ Place of public assembly Basis for flow calculation: <br /> 9. Factors that would affect the wastewater load: NO KNOWN FACTORS TO AFFECT LOADING <br /> 10. Type and location of proposed wastewater system: 4-60 ' CONVENTIONAL LINES, TYPE II, <br /> 12-18" TB; LOCATED 129' FROM THE SOUTH PROPERTY BOUNDARY AND 53' FROM THE <br /> EAST PROPERTY BOUNDARY (LOCATED SOUTHEAST OF PROPOSED STORE) <br /> 11. Design wastewater flow: 200 gpd(For flow>3,000 gpd and industrial process,duplicate plans shall be sent to the State.) <br /> Design wastewater strength: ❑X domestic ❑ high strength ❑ industrial process <br /> 12. A plat as defined in G.S. 130A-334(7a) is attached: ❑X Yes ❑ No <br /> 13. Location of proposed or existing wells(drinking water, irrigation,geothermal,groundwater monitoring, <br /> sampling,etc.)and any potable and non-potable water conveyance lines is indicated on attached plans and <br /> complies with 15A NCAC 18A.1950: ❑X Yes ❑ No <br /> This is a saprolite system. ❑Yes ❑ No <br /> 14. Evaluation(s)of soil conditions and site features in accordance with G.S. 130A-335(a1)signed and sealed by a <br /> LSS is attached: X❑Yes ❑ No <br /> 15. Evaluation of geologic and hydrogeologic conditions signed and sealed by a LG is attached ❑Yes X❑ NA <br /> 16. Proposed landscape,site, drainage,or soil modifications are attached: ❑Yesx❑ NA <br /> Attestation by Professional Engineer licensed in North Carolina pursuant to G.S.89C <br /> I, ATHAN M PARKER, PE hereby attest that the information required to be included with <br /> Registered Professional Engineer(Print Name) <br /> this Notice of Intent to Construct is accurate and complete to the best of my knowledge and that the proposed <br /> system shall meet applicable federal,State,and local laws, regulations, rules,and ordinances in accordance with <br /> G.S. 130A-336-.1(e)(6). ,,+t'"'""'f0f <br /> e xo,IlloaRKER4F.PEc-us EKING L*�.�"\,tr1 .AI S\r,`'. <br /> U RKR AMSOE EER a 0 �tiSS1p �y <br /> o� / <br /> Signature of Licensed Professional Engineer Date <br /> SEAL <br /> 43250 = <br /> �+f��i4�pir�t5ti <br /> DHHS/EHS/OSWP—EOP COMMON FORM Updated April 2022 Page 2 of 6 <br />