Voluntary Relinquishment of Septic PermitHarnett
COUNTY
NORTH CAROLINA
Division of Environmental Health
307 W. Cornelius Harnett Blvd.
Lillington, NC 27546
Ph: 910-893-7547
Fax: 910-893-9371
VOLUNTARY RELINQUISHMENT OF ADMINISTRATIVE APPEAL RIGHTS
March 14, 2016
McKee Homes, LLC
101 Hay Street
Fayetteville, NC 28301
Property location/site legal description: Oakmont S/D Lot 45 — 330 Bison Lane - #15-5-37645
Original Improvement Permit (IP) #28630 Issued 12-22-15
Original Authorization to Construct (AC) #28630 Issued 12-22-15
I, two 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) (which includes the IPs and ACs) in
order for the authorized agent/local health department to issue the applicable permit (new IP and/or CA) for the
site. I understand by completing this form that the permit(s) for a Pump to 25% Reduction System 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 IP and AC that the
current IP and AC must be revoked. I understand that the local health department's revocation of an IP or CA 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 reevvocation of the permit to take effect.
Signature of Property Owner: /�/
Date signed:
NCDHHS/DPH/EHS/OSWP Revised May 2015