WQ0031435_Sewer Extension_20070312

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USE -THE TAB KEY To
MOVE FIELD
Application Number: j
(to be completed by DWQ)
f.
Owner.
MAR 1. Z 2W
.1 a.
Town of Pembroke
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Full Legal Name (comp
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1 b.
McDuffie Cummins Tolawtv
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Signing Official Name and Title (Please review 15A NCAC 2H
.0206(b) for authorized signing officials!)
1 c.
The legal entitywho will own this system is:
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Individual [] Federal ® Municipality ❑ State/County ❑ Private
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Partnership ❑ Corporation ❑ Other (specity):
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1 d.
P.O. Box 866
'1 e. Pembroke
U.
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Mailing Address
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City
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1f.
North Carolina
1g. 28372-0866
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State _ _
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Zip Code
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1h.
910-521-9758 1i. 910-521-0472
.1j. [e-mail]
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Telephone Facsimile
E-mail
C)
2.
Project (Facility) Information:
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2a.
FY2005 CDBG Project, Arrow Point Subdivision, - Phase 1 B
2b. Robeson
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CC a
Brief Project Name (permit will refer to this name)
I County Where Project is Located
3.
Contact Person:
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3a.
Luke T-L Kwon , P.E. The Wooten Company
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b.
919-828-0531
3c. [e-mail]
Phone Number
E-mail
1.
Project is ® New ❑ Modification (of an existing permit)
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If Modification, Permit No.:
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For
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modifications, attach a separate sheet clearly explaining the reason for the modification (i.e. adding another
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.... �_ -.. � • ..�___•.. .�__-__ �.w
� !._i-..—_._ems-_ s_ u.!- -�_:a �--LL�.�u�.- J �f
THE WOOTEN COMPANY
ENGINEERING I PLANNING ;ARCHITECTURE
FIRST CITIZENS BANK AND'IRUST COMPANY
RALEIGH, NC 27602
120 N. Bovlan Avenue 66-30/5 31
Raleigh. NC
27603
919-828-0531
3/9/2007
Exactly Four hundred and no / 100 Dollars
Y
ITHE
:DER
NC DENR - DWQ
Raleigh NC
DATE
036789 36789
$400.00
Mv10UNT
TH*TENOMRANY -ACCOUNTS PAYABLE SIGNACURE
100 3 6 78 911' 1:0 5 3 100 3001:08 6 1 10008 91in
7. Volume of wastewater to be allocated for this particular project: 0 gallons per day
*Do not Include previously permitted allocations
8. If the permitted flow is zero, indicate why:
❑ Interceptor Line - Flow will be permitted in subsequent permits that connect to this line
® Flow has already been allocated in Permit No. W00029864
❑ Rehabilitation or replacement of existing sewer with no new flow expected
FTA 02/03 - Rev. 3 04105