WQ0022471_Sewer Extension Permit Status Update_20191119

Request for Engineering Certification Date of Letter: October 22,2019
Sewer Extension Permit Status Update
Please complete the applicable portion of this form for each permit and return this form and supporting documents to the attention
of Nyle Hothem at the Division's PERCS Unit by the delivery method below and within 30 days of the date of this letter:
NCDEQJDWR
WQPS—PERCS UNIT RECEIVED
By U.S. Postal Service: By Courier/Special Delivery: By Email:
1617 Mail Service Center 512 N.Salisbury St.Suite 925 Nyle Hothem NOV 9 1a19
Raleigh, NC 27699-1617 Raleigh, NC 27604 [e-mail]
Permit No.: WQ 0 0 2 2 4 71 Permittee: Town of Tarboro
Project Name: Triplexes for the Elderly
Project Status (Check appropriate box to indicate Permittee's response and complete &sign below)
❑ Permit to Remain Open: The Permittee certifies that the permitted project has not been constructed but shall be constructed in
the future in conformity with the approved Permit, project plans,specifications,and supporting documents.The Permittee
understands that the appropriate certification documents will need to be forwarded to the Division prior to operation. Subject
permit shall be maintained in Active status.
❑ The Permitted project has been constructed and the required Engineer's Certification and supporting documents will be
submitted to the Division with this form. Permittee understands that failure to submit required certification documents for an
active, in-service system may result in enforcement action.
O Request Extension: Permittee requests extension to reply to this letter not to exceed 60 days of the date of this letter.
❑ Ownership/Name Change: The Permittee requests information to apply for ownership or name change. Please provide email
and phone number below for follow-up.
Name&Title(print): John K. Moore, Director of Public Works
Signature: t& • r . 1, i Date: Gl//
Comments: S ial no. 0300378 Has been completed
Permit Rescission Request
The Permittee requests that the subject permit be rescinded and certifies that the permitted sewer system has not been and shall
not be constructed nor made operational.We understand that,in the future,should we wish to operate a non-discharge sewer
system,we shall apply for and receive a new Wastewater Collection System Permit.
Name&Title(Print):
Signature: Date:
Comments:
Contact Information Updates for Current Owner
Updated Contact Person&Title(Print):
Updated Mailing Address:
Updated Email: Updated Phone: