WQ0036360_More Information (Received)_20190614

Sewer Extension Permit Status Update
Permit No.: 0 03 o 3t° Permittee: v C,si1_A(E c i i(P ' err)?L ref c
Project Name:
• For multiple permits with the same status,please attach a supplementary page indicating all permit numbers and project
names of the permits being addressed by this form.
Please complete the applicable remaining portion of this form and return to the Division at:
NCDEQ/DWR
WQPS—PERCS UNIT
By U.S.Postal Service: By Courier/Special Delivery: By Email:
1617 Mail Service Center 512 N.Salisbury St.Suite 925 Nyle Hothem
Raleigh, NC 27699-1617 Raleigh, NC 27604 [e-mail]
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Permit Shall Remain Open
We certify that the subject permit(s) has not yet been constructed but shall be constructed in the future in conformity with
the approved project plans,specifications,and supporting documents
OR that this project is currently under construction but is not yet in operation.
We understand that the appropriate certification documents must be forwarded to the Division prior to operation.
Please maintain the subject permit(s)in active status.
Name&Title(print):
Signature: Date:
Comments:
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Permit Rescission Request
We request that the subject permit(s)be rescinded and certify that the permitted sewer(s)have not been and shall not be
constructed nor made operational.We understand that,in the future,should we wish to operate a non-discharge sewer
system,
we shall apply� for Pandd�receei rivea new Wastewater Collection System Permit.
�Name&Title(Print): J< icT / R / (.4 f/� I / P 6 /0 6A /
Signature: ` Date: a‘h/ /9--0/Ci
Comments: &.titiM Ad A CA 4-1- 4 v- (AAA di ci l�✓� A he
lernA 'Jed frwfc1 - ;fit, •.r;
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Contact Information Updates:
To update your contact information,including mailing address,please list that information below:
Updated Contact Person:
Updated Mailing Address:
Updated Email: