WQ0021680_Sewer Extension Permit Status Update_20191203

RECEIVED
DEC 0 3 2019
NCDEQ/DWR/NPDEB
TO: Christyn L. Fertenbaugh (
Environmental Engineer
1617 Mail Service Center
Raleigh,NC 27699-1617
In Response to the letter on Requested Certifications
WQ0022965 Coffin woods subdivision
Certification included
WQ0021680 Deep River Haven Industrial Park
Request Extension
We have contacted the Engineer and they are unable to Find
? Is the number Correct ?
Arnold Allred
336-736-4185
Arnold.Allred triadbi .rr.com
Public Works Director 11-26-19
cc: Jeff Bryan (Environmental Engineer)

IX. CERTIFICATIONS:
1. Does the submitte I system comply with 15A NCAC 02T,the Minimum Design Criteria fir the Permitting of Pump Stations
and Force Mains(fittest version",and the Gravity.Sewer Minimum Design Criteria(latest version)as applicable?
Yes ❑No
If No, complete a; d submit the Variance/Alternative Design Request application (VADC 10-14)and supporting documents
for review. App oval of the request is required prior to submittal of the Fast Track Application and supporting
documents.
2. Professional Engineer's Certification:Ati
t
I, 1 C, nQ I D . AD/1 attest that this application for
Professional Engineer's namejfrom Application Item 1I1.1.)
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Co Pi- WUor�s �Sc,,bdi! t s. w4Qoz Gs
(Facility name from Application Item II.I.)
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has been reviewec by me and is accurate, complete and consistent with the information supplied in the plans, specifications,
engineering calcultions,and all other supporting documentation to the best of my knowledge. I further attest that to the best
of my knowledge he proposed design has been prepared in accordance with this application package and its instructions, as
well as all applicable regulations and statutes. Although other professionals may have developed certain portions of this
submittal package inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to b consistent with the proposed design.
NOTE - In accordance with General Statutes 1143-21.5_6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 isdemeanor, which may
include a fine not o exceed$10,000,as well as civil penalties up to$25,000 per violation.
North C; rolina Professional Engineer's seal,signature,and date: H CAR
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3. Applicant's Certification per 1 A NCAC 2T .0106(bj.:
I, 4- / 6 I,� 1.�ag-k5 I.ft&kit - attest that this application for
(Sig ature Authority's name&title from Application Item 1.3.)
•c,i 11�I,' I C tr4 Loci too 7f"!a f n t I -
(Facility name from Application Item 11.1.)
has been reviewe by me and is accurate and complete to the best of my knowledge. I understand that any discharge of
wastewater from ►tis non-discharge system to surface waters or the land will result in an immediate enforcement action that
may include civil ienalties, injunctive relief,and/or criminal prosecution. I will make no claim against the Division of Water
Resources should t condition of this permit be violated. I also understand that if all required parts of this application package
are not completed and that if all required supporting information and attachments are not included, this application package
will be returned tc me as incomplete.
NOTE - In acco dance with General Statutes 143-215.61 and 143-215.03, any person who knowingly makes any false
statement, representation, or certification in any application ge shall be guilty of a Class 2 misdemeanor, which may
include a fine not o exceed$10,000 as wel civil penalf tip to$25,000 per violation.
Signature:_ C/ Date: //- , 1.2410
FORM: SSEA 04-16 Page 6 of 6

Request for Engineering Certificat n Date of Letter: October 22,2019
Sewer Extension Permit Status Update
Please complete the applies ble portion of this form for each permit and return this form and supporting documents to the attention
of Nyle Hothem at the Divi__<on's PERCS Unit by the delivery method below and within 30 days of the date of this letter:
NCDEQ/DWR
WQPS—PERCS UNIT RECEIVED
By U.S. Postal Service By Courier/Special Delivery: By Email:
1617 Mail Service Cen er 512 N.Salisbury St.Suite 925 Nyle Hothem DEC 03 2019
Raleigh, NC 27699-16 .7 Raleigh, NC 27604 [e-mail]
Permit No.: t4 Uo nnO Permittee: Town of Franklinville
Project Name: �°r(P ,Q yC r 1-44 x ,t/ . r-cks f a til P 1!C
Project Status(Check appropriate box to indicate Permittee's response and complete & sign below)
❑ Permit to Remain Opelt: The Permittee certifies that the permitted project has not been constructed but shall be constructed in
the future in conform y with the approved Permit,project plans,specifications,and supporting documents.The Permittee
understands that the ppropriate 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 Divi. on with this form. Permittee understands that failure to submit required certification documents for an
active,in-service systt m may result in enforcement action.
equest Extension: P amittee requests extension to reply to this letter not to exceed 60 days of the date of this letter.
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❑ Ownership/Name Change. The Permittee requests information to apply for ownership or name change. Please provide email
and phone number bi low for follow-up.
Name&Title(print):
Signature: _ Date:
Comments:
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 mode operational.We understand that, in the future,should we wish to operate a non-discharge sewer
system,we shall apply foi 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 Addres :
Updated Email: _.__. __Updated Phone: _
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