WQ0045329_Application_20240422

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LualeS-U04SUIM Department of Environmental Quality
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15A AC 02T .0200 — WASTEWATER PUMP AND HAUL SYSTEMS
Division of Water Resources ��NSTRIV49W1©" FOR FORM P&H 11-23 & SUPPORTING DOCUMENTATION
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Documents shall be prepared in accordance with 15A NCAC 02T .0100.15A NCAC 02T .0200, and Division policies. Failure to submit
all required items will necessitate additional processing and review time. For more information, visit the Wastewater Branch's
website or contact the Regional Office serving your county.
General —This permit application applies to all pump and haul activities of wastewater under the authority of the Division on Water
Resources. Permit coverage is required for the system producing the wastewater. This permit does not apply to the transport of
animal waste from an animal waste management systems, nor the transport of wastewater residuals or biosolids.
NOTE: Pump and haul permits are not acceptable long term domestic wastewater treatment alternatives and shall only be issued
in cases of environmental emergencies, nuisance conditions, health problems, or for unavoidable delays in construction of system
previously permitted by the Division.
The Applicant shall submit one original and one copy of the application and supporting documentation.
A. Pre -submittal Contact & Cover Letter
® Contact the appropriate Regional Office prior to submittal
® Submit a cover letter explaining the circumstances associated with this pump and haul permit request
B. Application Fee (Domestic Wastewater Only)
® Submit a check made payable to: North Carolina Department of Environmental Quality (NCDEQ)
➢ The appropriate application fee is: $1,160.00 for flows < 10,000 GPD and $1,760.00 for flows > 10,000 GPD
C. Wastewater Pump and Haul (FORM: P&H 11-23) Application:
® Submit the completed and appropriately executed Wastewater Pump and Haul (FORM: P&H 11-23) application. Any
unauthorized content changes to this form shall result in the application package being returned. If necessary for clarity or
due to space restrictions, attachments to the application may be made, as long as the attachments are numbered to
correspond to the section and item to which they refer
D. Receiving Facility Letter:
® Submit a letter from the owner/authority of the receiving wastewater treatment facility, as required by 15A NCAC 02T .0204
(b), stating that the pumped and hauled wastewater will be accepted and specifying the volume and type of wastewater that
will be accepted. The letter should be signed by an authorized signing official in accordance with 15A NCAC 02T .0106(b)
E. Contract Hauler Letter:
® Submit a letter from the hauler stating their capability and willingness to perform the pump and haul activity
® Letter shall include: Owner/Company Name, Contact Information, & Hauling Volume of Vehicle(s)
F. Certifications:
® The Applicant's Certification on Page 4 of the application shall be signed in accordance with 15A NCAC 02T .0106(b). Per 15A
NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from a
person who meets the criteria in 15A NCAC 02T .0106(b)
® The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North Carolina
licensed Professional Engineer (if required)
G. Plans and Specifications (Required for activities that result in the Practice of Engineering per G.S. 89C-3):
® Submit one set of printed plans and specifications (signed, sealed and dated by a N.C. Licensed Professional Engineer) and
provide one copy in digital electronic format (PDF file)
® Plans must include:
➢ A general location map
➢ Diagram of the components associated with the pump and haul activity (drains, piping, tanks, pumps, etc)
➢ Tank Details that indicate high water alarm
➢ Other items as required
INSTRUCTIONS FOR APPLICATION P&H 11-23 Page 1 of 5

Industrial Pump and Haul Activities
Per 15A NCAC 02T .0203(A)(2), Industrial pump and haul activities are deemed permitted provided the following criteria is met:
The facility notifies the appropriate Division regional office in writing advising of the type of operation, type and quantity of
wastewater generated, location, and the receiving wastewater treatment facility. A letter from the facility accepting the
wastewater (type and quantity) specifically agreeing to accept wastewater from the applicant shall be included.
➢ The wastewater does not contain any human waste.
➢ The waste is collected and discharged into a sewer or treatment system designed and permitted to accept the type of
wastewater being pumped and hauled.
Y The pump and haul activity is not to alleviate a failing wastewater system.
Y The Division regional office concurs in writing that the activity meets the criteria in this Rule.
CONTACT THE REGIONAL OFFICE PRIOR TO INITIATING ANY INDUSTRIAL PUMP AND HAUL ACTIVITES. SUBMITTAL OF THIS
APPLICATION/DOCUMENTS AND WRITTEN APPROVAL IS STILL REQUIRED FOR INDUSTRIAL PUMP AND HAUL ACTIVITIES
THE COMPLETED APPLICATION PACKAGE INCLUDING ALL SUPPORTING INFORMATION AND MATERIALS, SHOULD BE SENT TO THE
APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Water Quality Operations
Swannanoa, North Carolina 28778
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett, Hoke,
Water Quality Operations
Fayetteville, North Carolina 28301
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Water Quality Operations
Mooresville, North Carolina 28115
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
Raleigh Regional Office
1628 Mail Service Center
Chatham, Durham, Edgecombe, Franklin,
Water Quality Operations
Raleigh, North Carolina 27699-1628
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
Washington Regional Office
943 Washington Square Mall
Beaufort, Bertie, Camden, Chowan, Craven,
Water Quality Operations
Washington, North Carolina 27889
Currituck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington, Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water Quality Operations
Wilmington, North Carolina 28405
Hanover, Onslow, Pender
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Alamance, Alleghany, Ashe, Caswell, Davidson,
Suite 300
Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
(336)-776-9800
INSTRUCTIONS FOR APPLICATION P&H 11-23 Page 2 of 5

I. PRESUBMITTAL INFORMATION:
1. Contacted representative from regional office (Pre -submittal)?: ® Yes ❑ No
2. Contact name (For Regional Office): Caitlin Williams
II. APPLICANT INFORMATION:
1. Applicant's name (Municipality, Individual, Corporation, etc): City of King, NC
2. Applicant type: ® Municipal ❑ State ❑ Privately -Owned Public Utility
❑ County ❑ Other:
3. Origin of Wastewater:
® Residential Subdivision ❑ Retail (Stores, Shopping Centers)
❑ Apartments/Condominiums ❑ Institution
❑ Mobile Home Park ❑ Hospital
❑ School ❑ Church
❑ Restaurant ❑ Nursing Home
❑ Office ❑ Other (specify)
4. Signature authority's name: Benjamin S. Marion per 15A NCAC 02T .0106(b)
Title: City Engineer Intern
5. Applicant's mailing address: PO Box 1132
City: King State: NC Zip: 27021-
6. Applicant's contact information:
Phone number: [phone] Email: [e-mail]
III. CONTACT/CONSULTANT INFORMATION:
1. Contact name: Scott Snyder
Title/Affiliation: Project Manager
2. Contact's information:
Phone number: [phone] Email: [e-mail]
Iv. RECEIVING FACILITY INFORMATION:
Domestic:
Commercial
Industrial:
Other:
100
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: City of King
2. Facility name: Muddy Creek WWTP
3. Facility permit number: NCO050342
4. WWTF permit number: NCO050342
5. WWTF contact name: Beniamin S. Marion
Title/Affiliation: City Engineer Intern
6. WWTF contact information:
Phone number: [phone] Email: [e-mail]
APPLICATION P&H 11-23 Page 3 of 5

V. PROJECT INFORMATION:
1. Project Name: Muddy Creek Pump Station Replacement
2. Project Location: Stokes/Forsyth county
3. Duration of Pump and Haul Request (not to exceed 6 months): 6 months
4. Has a prior permit been issued?
❑ New ® Prior Pump & Haul Permit
Permit No.: WQ0044791
5. Permanent Method of Wastewater Disposal: The wastewater will be collected at a new pump station to be
constructed near the proposed pump and haul site and conveyed via a newly constructed 12-inch FM and connected to
an existing 14-inch FM along King-Tobaccoville Road.
6. Date Permanent Disposal will be available: December 2024
7. Have permits / approvals for permanent disposal been obtained?
a. ® Yes ❑ No Permit Number: WQ0044791
8. Is there a Pretreatment Program in effect? ❑ Yes ®No
9. Describe any pretreatment prior to pumping and hauling: N/A
10. Volume of Wastewater Generated: 3,635 Gallons per Day
11. Explain how the wastewater flow was determined: ❑ 15A NCAC 02T .0114 or ® Representative Data
If representative data, describe: Based off the current pump and haul data over the last several months, the
average daily flow in approximately 1,215. or 75 gpd/bedroom, if applicable (House Bill 600 Section 18)
12. Describe Tank / Container wastewater will be pumped from (attach description if necessary):
Two 9'x9'x3' square wet wells will be connect to provide approximately 3,635 gallons minimum 24 hour
storage.
13. Is Tank / Container in place or will it be installed (attach description if necessary):
b. In place
14. What type of high water alarm does the container have:
2. ® Audible and Visual ❑ Telemetry (Auto Dialer / SCADA)
VI. CERTIFICATION:
1. Applicant's Certification: (Signature of Signing Official and Project Name)
I, Benjamin S. Marion , attest that this application for City of King 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. I 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-
215.66any 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.
1a.
Signing 9fcial Signature Date
APPLICATION P&H 11-23 Page 4 of 5

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 .0204(d).
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.
Professional Engineer's Certification: (Signature of Design Engineer and Project Name)
I, Scott Snyder ,attest that this application for The City of King 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 143-215.68, 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.
?a. Scott Snyder
Professional Engineer Name
KCI TECHNOLOGIES INC.
Engineering Firm
106 Clair Drive
Mailing Address
Piedmont
City
864-714-1288
Telephone
2e. SC 2f. 29673
State Zip
�2h. 2i. [e-mail]
Facsimile E-mail
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APPLICATION P&H 11-23 Page 5 of 5