NC0020443_Pump and Haul Request_20230623

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1. PRESUBMITTAL INFORMATION:
1. Contacted representative from regional office (Pre -submittal)?: [L]' Yes ❑ No
2. Contact name (For Regional Office): &k Ij,C k } `> � ` ^, i %,,I a (
11. APPLICANT INFORMATION:
1. Applicant's name (Municipality, Individual, Corporation, etc): aog" t?13,in5 t4;R1'bW' 9.4y, ,j
2. Applicant type: ❑ Municipal ivrState ❑ Privately -Owned Public Utility
❑ County ❑ Other:
3. Origin of Wastewater:
❑ Residential Subdivision ❑ Retail (Stores, Shopping Centers) Domestic: %
❑ Apartments/Condominiums ❑ Institution Commercial: %
❑ Mobile Home Park ❑ Hospital Industrial: %
❑ School ❑ Church Other: } oc %
❑ Restaurant ❑ Nursing Home
❑ Office 21 Other (specify) wd 4t-
4. Signature authority's name: per 15A NCAC 02T .0106,jb� nau,`d
Title: b_,1jeJpI #Aa ,Je^ a4ce Sgety so,-
5. Applicant's mailing address:' aF-
! Cit : y ���State: � C Zip: z.Jtrs3
6. Applicant's contact information:
Phone number:2j =3i
III. CONTACT/CONSULTANT INFORMATION:
1. Contact name:
Title/Affiliation:
2. Contact's information:
Phone number: (_) Email:
IV. RECEIVING FACILITY INFORMATION:
PArr-
Email: ".,E'naa"i .;,"
RECEIVED
J U N L 3 LJ�3
NCDEQ/DWR/NPDES
If more than 1 facility has agreed to accept the wastewater, please list all the owners, facility names, and permit
numbers as a separate attachment)
1. Owner: i"aw o i­,14 w+ , 01, Aj C
2. Facility name: e-akmb. 3 ,0 T_?
3. Facility permit number:
4. WWTF permit number: NC- oc 4 k 7
S. WWTF contact name: C,, u3 �, k, 110o, °I 19aft0le`—
Title/Affiliation: o Mj tire,--
6. WWTF contact information:
Phone number: i§ aj { Email: rke #_
APPLICATION P&H 01-16
Page 3 of 5

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V. PROJECT INFORMATION:
1. Duration of Pump and Haul Request (Six Months Typical):
2. Has a prior permit been issued? ® New ❑ Prior Pump & Haul Permit
Permit No.:
3. Permanent Method of Wastewater Disposal: tad ile 1�A o- 4e G4-L1-f-C t'''ta*444"
4. Date Permanent Disposal will be available: j � .z jz j
5. Have permits / approvals for permanent disposal been obtained?
❑ Yes &r No Permit Number:
6. Is there a Pretreatment Program in effect? ❑ Yes ® No
7. Describe any pretreatment prior to pumping and hauling:
8. Volume of Wastewater Generated: G ( Gallons per Day
9. Explain how the wastewater flow was determined: ❑ 15A NCAC 021 -0114 or ❑ Representative Data
If representative data, describe: f Mc 4-4"
10. Describe Tank / Container wastewater will be pumped from (attach description if necessary):
r 5�--.11( f tpa�+�-.. l V'k-
11. Is Tank / Container in place or will it be installed (attach description if necessary): L =; f 1,),: .
12. What type of high water alarm does the container have:
Audible and Visual ❑ Telemetry (Auto Dialer / SCADA)
VI. CERTIFICATION:
----- - -- - .— _ ---- - — - _ .
�1. Applicant's Certification: (Signature of Signing Official and Project Name)
I
attest that this application for J' �y.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 documentation and attachments are not included, this application package is subject to
being returned as incomplete. 1 understand that issuance of a permit will require pump and haul facilities or activities to be
inspected at least daily by me or a designated representative. Note: In accordance with North Carolina General Statutes 143-
215.6A and 143-215.613, any person who knowingly makes any false statement, representation, or certification in any
application shall be guilty of a Class 2 misdemeanor, which may include a fine not to exceed $10,000 as well as civil penalties
up to $25,000 per violation.
Signing Official Signature Date
ENGINEERING DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL.
ACTIVITIES SHALL BE INSPECTED AT LEAST DAILY BY THE PERMITTEE OR IT'S REPRESENTATIVE PER 15A NCAC 02T .02041d).
APPLICATION P&H 01-16
RECEIVED
JUN u 3
Page 4 of 5
Tr)/DWR/NPDES

THE ENGINEER'S CERTFICATION IS REQUIRED FOR ACTIVITIES THAT RESULT IN THE PRACTICE OF ENGINEERING PER G.S. 89C-3.
ENGINEERING DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL. IF CERTIFICATION BY AND ENGINEER IS REQUIRED,
THIS PAGE IS NOT NECESSARY.
2. Professional Engineer's Certification: (Signature of Design Engineer and Project Name)
I, ,attest that this application for has been reviewed by me and is
accurate, complete and consistent with the information in the engineering plans, calculations, and all other supporting
documentation to the best of my knowledge. I further attest that to the best of my knowledge the proposed design has been
prepared in accordance with all the applicable regulations. 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 be consistent with the proposed design. Note: In accordance with NC General Statutes 143-215.6A and
143-21S.6B, any person who knowingly makes any false statement, representation, or certification in any application shall be
guilty of a Class 2 misdemeanor which may include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per
violation.
2a.
Professional Engineer Name
b.
Engineering Firm
c.
Mailing Address
d. 2e. 2f.
City State Zip
g. 2h. 2i.
Telephone Facsimile E-mail NC PE Seal, Signature & Date
RECEIVED
Jp "0
LUG,,
NCDEQ/DWR/NPDES
Signature for approval of payment by:
[DOCUSIgned
au 06Ut .,V'
0 6/ 16 / 2 0 2 3 B29376219CA74A3_
APPLICATION P&H 01-16 Page 5 of 5

Water
Pump & Haul Systems Permit (Wastewater)
What Activities Require This Permit? Disposal of wastewater, permitted under the Division of Water Resources, by
pumping and hauling the wastewater to an alternate, permitted disposal facility. Pump and haul systems that are not
permitted by regulation (refer to 15A NCAC 02T .0203) can be permitted in cases of environmental emergencies,
nuisance conditions, health problems, or for unavoidable delays in construction of systems permitted under the authority
of the Division of Water Resources.
What Is The Purpose of This Permit? This is a short-term alternative to ensure the proper disposal of domestic
wastewater for systems meeting the requirements listed in 15A NCAC 02T .0200.
Who Issues This Permit? N.C. Division of Water Resources, Water Quality Regional Operations Section.
How Much Will This Permit Cost? The application fee for a pump and haul permit is $810 for flows less than
10,000 gallons per day (GPD) and $1,310 for flows greater than 10,000 GPD.
What Are My Payment Options for Permit Application Fees? Check
If Paying by Check, Who do I Make the Check Payable to and Where Do I Send the Check? Make check
payable to NC DEQ; include check with application. For information on where to send the application, see the section
below titled "Where Do I Submit My Application."
Where Can I Get The Application For This Permit?
An application for a Wastewater Pump and Haul Permit consists of: (a) one original and a copy of the completed and
appropriately executed application form (obtained from the appropriate regional office); (b) two sets of detailed plans and
specifications signed and sealed by a North Carolina Registered Professional Engineer if required by the regional office;
(c) the permit processing fee; (d) a letter must be provided from the owner/authority of the wastewater treatment facility
stating that the wastewater (type and volume) will be accepted; and, (e) a copy of the contract or agreement between
the wastewater hauler and the applicant and a map indicating the haul route. The letter (d) should be dated within 30
days of the permit application and should refer to the project by the same name as that identified on the application and
the plans/specifications. Contact the appropriate regional office of the Water Quality Regional Operations Section for
copies of the checklist and rules: http://deg.nc.gov/contact/regional-offices.
How Long Will It Take To Review My Application? For a complete application, review time is approximately two
weeks or less.
Where Do I Submit My Application? Pump and haul permit applications are to be submitted to the appropriate
regional office of the Division of Water Resources, Water Quality Regional Operations Section. Visit the following link for
regional office contact information: http://deg.nc.gov/contact/regional-offices.
How Long Is My Permit or License or Certificate Valid? 6 Months.
Notes/Comments: None.
Legal Authority/Statute Reference: NCAC 15A 02T .0200, G.S. 143-215.1; 143-215.3(a)
Link: https://deg.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/collection-
systems/pump-haul
Statewide Contact Information:
NC Division of Water Resources
Municipal Permitting Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Telephone: [phone]
Fax: [phone]
NC DEQ Permit Directory Updated 11/20