790012_Application_20220913

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Animal Feeding Operations Permit Application Form
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
State Individual Permit - Existing Animal Waste Operations
1. GENERAL INFORMATION:
1.1 Facility name: ��,t') e4/� t. / -'
NC DEQ/DWR
1.2 Print Land Owner's name: giviY 0.01(146 Central Office
1.3 Mailing address: a-/ ,-jy1,„64 /-
City, State: ,f'pk/ Atd 734d' Zip: 027.5c) !�
Telephone number (include area code): ( 3.54 30y 2/7�.3 - 33G -93 7 ` 5 47'4'6
1.4 Physical address:2-/, -7/M 44.A ) L
City, State "h Uil/e ? Zip: 291�
Telephone number (include area code): (/3J 3 "f- 4/7.13
jf 1.5 County where facility is located: k-/A 'I/!'/� /
1.6 Facility location (directions from nearest major highway, using SR numbers for state roads): JJ o
1.7 Farm Manager's name (if different from Land Owner):
1.8 Lessee's / Integrator's name (if applicable; circle which type is listed):
vslIAD Roma
somy,o-t..1
zzOz g I d3S
1.9 Facility's original start-up date:
RECEIVED
SEP 12 2022
Date(s) of facility expansion(s) (if applicable):
2. OPERATION INFORMATION:
de-s�y 9
2.1 Facility number: R W /79DD%� � ! ` /
2.2 Operation Description:
D
Please enter the Design Capacity of the system. The "No. of Animals" should be the maximum number for which the
waste management structures were designed.
Type of Swine No. of Animals Type of Poultry No. of Animals Type of Cattle No. of Animals
❑ Wean to Feeder ❑ Layer ❑ Beef Brood Cow
❑ Feeder to Finish ❑ Non -Layer ❑ Beef Feeder
❑ Farrow to Wean (# sow) ❑ Turkey ❑ Beef Stocker Calf
❑ Farrow to Feeder (# sow) ❑ Turkey Poults ❑ Dairy Calf
❑ Farrow to Finish (# sow) ❑ Dairy Heifer
❑ Wean to Finish (# sow) ❑ Dry Cow
❑ Gilts ❑ Milk Cow
❑ Boar/Stud
Other Type of Livestock on the farm:
No. of Animals:
r3S
FORM: AWO-STATE-I-E 1/10/06 Page 1 of 5

2.3 Acreage cleared and available for application (excluding all required buffers and areas not covered by the application
system): 030 Required Acreage (as listed in the CAWMP):
2.4 Number of lagoons: API- Total Capacity (cubic feet): Required Capacity (cubic feet):
Number of Storage Ponds: /V t. Total Capacity (cubic feet): Required Capacity (cubic feet):
2.5 Are subsurface drains present within 100' of any of the application fields? YES or PTO (circle one)
2.6 Are subsurface drains present in the vicinity or under the waste management system? YE or (circle one)
2.7 Does this facility meet all applicable siting requirements?
2.8 Brief description of treatment process:
3. REQUIRED ITEMS CHECKLIST:
or NO (circle one)
Please indicate that you have included the following required items by signing your initials in the space provided next to each
item.
Applicants Initials
3.1 One completed and signed original and two copies of the application for State Individual Permit A
- Animal Waste Operations; �(J
3.2 Three copies of a general location map indicating the location of the animal waste facilities and
field locations where animal waste is land applied and a county road map with the location of
the facility indicated;
3.3 Three copies of the entire Certified Animal Waste Management Plan (CAWMP). If the facility
does not have a CAWMP, it must be completed prior to submittal of a permit application for
animal waste operations.
The CAWMP must include the following components. Some of these components may not have been required at the time
the facility was certified but should be added to the CAWMP for permitting purposes:
3.3.1 The Waste Utilization Plan (WUP) must include the amount of Plant Available Nitrogen (PAN) produced and
utilized by the facility
3.3.2 The method by which waste is applied to the disposal fields (e.g. irrigation, injection, etc.)
3.3.3 A map of every field used for land application
3.3.4 The soil series present on every land application field
3.3.5 The crops grown on every land application field
3.3.6 The Realistic Yield Expectation (RYE) for every crop shown in the WUP
3.3.7 The PAN applied to every land application field
3.3.8 The waste application windows for every crop utilized in the WUP
3.3.9 The required NRCS Standard specifications
3.3.10 A site schematic
3.3.11 Emergency Action Plan
3.3.12 Insect Control Checklist with chosen best management practices noted
3.3.13 Odor Control Checklist with chosen best management practices noted
3.3.14 Mortality Control Checklist with the selected method noted
3.3.15 Lagoon/storage pond capacity documentation (design, calculations, etc.); please be sure to include any site
evaluations, wetland determinations, or hazard classifications that may be applicable to your facility
3.3.16 Operation and Maintenance Plan
If your CAWMP includes any components not shown on this list, please include the additional components with your
submittal. (Composting, waste transfers, etc.)
FORM: AWO-STATE-I-E 1/10/06 Page 2 of 5

This form must be completed by the appropriate DWR regional office and included as a part of the
project submittal information.
INSTRUCTIONS TO NC PROFESSIONALS:
The classification of the downslope surface waters (the surface waters that any overflow from the facility would flow toward) in
which this 'animal waste management system will be operated must be determined by the appropriate DWR regional office.
Therefore, you are required, prior to submittal of the application package, to submit this form, with items 1 through 6
completed, to the appropriate Division of Water Resources, Water Quality Regional Operations Supervisor (see page 6 of 10).
At a minimum, you must include an 8.5" by 11" copy of the portion of a 7.5 minute USGS Topographic Map which shows the
location of this animal waste application system and the downslope surface waters in which they will be located. Identify the
closest downslope surface waters on the attached map copy. Once the regional office has completed the classification,
reincorporate this completed page and the topographic map into the complete application form and submit the
application package.
6.1 Farm Name:
6.2 Name & complete address of engineering firm:
Telephone number: (
V`
6.3 Name of closest downslope s ters:
6.4 County(ies) wh
6.5 Map name
6.6 NC Professional's Seal (If appropriate), Signature, and Date:
S
nimal waste management system and surface waters are located
TO: WQROS SUPERVISOR
Please provide me with the classification of the watershed where this animal waste management facility will be or has been
constructed or field located, as identified on the attached map segment(s):
Name of surface waters:
Classification (as established by the ryQy e a 1a ment Commission):
Proposedjcl ification, if a i ble
Signa e�ot regional of ice personnel:
(All attachmentsmust be signed)
Date:
FORM: AWO-STATE-I-E 1/10/06
Page 4 of 5

4. APgLICANT'S CERTIFICATION:
I, I /1/#446 4,�'//11_$'`/fe,e (Land Owner's name listed in question 1.2), attest that
this application for A//a1/y',C®G) (Facility name listed in question 1.1)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of this
application are not completed and that if all required supporting information and attachments are not included, this application
package will be returnedetpme as incomplete.
Signature f"i/`�tr Date 7— 9— a O.. .2.1
5. MANAGER'S CERTIFICATION: (complete only if different from the Land Owner)
I, (Manager's name listed in question 1.6), attest that this
application for (Facility name listed in question 1.1)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of this
application are not completed and that if all required supporting information and attachments are not included, this application
package will be returned as incomplete.
Signature Date
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING INFORMATION AND MATERIALS,
SHOULD BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DIVISION OF WATER RESOURCES
WATER QUALITY REGIONAL OPERATIONS SECTION
ANIMAL FEEDING OPERATIONS PROGRAM
1636 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1636
TELEPHONE NUMBER: [phone]
FAX NUMBER: [phone]
6. SURFACE WATER CLASSIFICATION:
FORM: AWO-STATE-I-E 1/10/06 Page 3 of 5

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