A-6 Affidavit of On-Site Wastewater Existing System

APPENDIX H

AFFIDAVIT OF ON-SITE WASTEWATER EXISTING SYSTEM PURSUANT TO N.C.G.S. §160D-1110(h1)

[This form is only required with a permit application if the permit applicant is applying for exemption as allowed by N.C.G.S. § 160D-1110(h1)]

STATE OF NORTH CAROLINA

COUNTY OF _______________________

___________________________________ Inspection Department

Address and Parcel Identification of Real Property Where Building is to be Constructed or Altered:
_____________________________________________________________________________________________
_____________________________________________________________________________________________

I, ___________________________________________________________________________________________,
(Print Full Name)
owner of the property, do hereby under penalties of perjury affirm that the proposed building construction will meet local and State on-site wastewater system setback requirements pursuant to N.C.G.S. § 130A-335. Additionally, the proposed construction shall not increase the design daily flow or wastewater strength of the existing system and thereby absolves the State, Inspection Department, and Local Health Department of any responsibility or liability regarding the existing wastewater system.

The property owner may, at his or her discretion, consult with an authorized on-site wastewater evaluator certified by the North Carolina On-Site Wastewater Contractors and Inspectors Certification Board or an inspector, as defined in N.C.G.S. § 90A-71(5), to locate the on-site wastewater existing system and verify setbacks requirements prior to executing this affidavit.

_____________________________________________________ _____________________
(Signature of Affiant) Date

Sworn to (or affirmed) and Subscribed before me this the _____ day of __________________, 20___

___________________________________
Signature of Notary Public

___________________________________
Printed Name of Notary Public

My Commission Expires: ______________________ (Notary Stamp or Seal)