NCS00167_2023Permit_Initial

2023
Permit and Registration
Ketcham Septic Tank
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-00167
o and registered as a
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NORTH
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-�� Septage Management Firm�� �� w� ��nffii�utr
E� M
NORTH CAROLINA (PUMPER)
Environmental Quality
in the State of North Carolina.
This permit to operate a Septage Management Firm is issued to the above named person, business or entity alone and is not transferable to any other person, business or entity.
Firm operation shall be in accordance with the provisions of N.C. General Statute 130A-291.1 - 130A-291.3, Title 15A of the N.C. Administrative Code 13B .0800 et.seq.,
conditions of the permit, and representations made in the application and accompanying documents for a permit.
The permit holder is authorized to discharge septage only at the locations(s) listed below:
1. Lexington Regional WWTP, Lexington, NC
This permit does not entitle the permit holder to operate a Septage Land Application Site, a Septage Detention or Treatment Facility, or any other solid waste management facility
not specified herein.
Failure to operate as permitted may result in the Department suspending or revoking this permit, initiating action to enjoin the unpermitted operation, imposing administrative
penalties, or invoking any other remedy as provided in Chapter 130A, Article 1, part 2 of the North Carolina General Statutes. This permit and registration expires on
December 31, 2023.
Wrn Perry Sugg
Digitally signed by Wm Perry
Sugg
Date: 2023.02.02 12:19:03-05'00'
Perry Sugg, Environmental Compliance Branch Head

For questions regarding this form or the online application process, please contact Jeffrey Bullard (919-707-8285) or Chester Cobb (919-707-
8283).
Firm Info
Firm name*
ketcham septic tank
The "Firm name" must be exactly as it is shown on your vehicle(s).
Septage Management Firm permit number (NCS #)
NCS-167
Enter the five digits following the NCS #
Street address of office*
Street Address
185 SCOTT DR
Address Line 2
City
State / Province / Region
LEXINGTON
NC
Postal / Zip Code
Country
27295-7462
davidson
County*
Davidson
Mailing address same as street address of office?*
Yes • No
Mailing Address*
Street Address
po box 1223
Address Line 2
City
State / Province / Region
welcome
n.c.
Postal / Zip Code
Country
27374
United States
Phone* Fax
13367314330
Email*
[e-mail]
Owner Info
Firm owner's name*
Joel ketcham
Mailing address same as street address of office?*
• Yes No
Phone* Fax
3362428891

Operator Info ^�
Firm operator's name* Firm operator's title
Joel ketcham
Mailing address same as street address of office?*
• Yes No
Phone* Fax
3362428891
Type and amount of septage pumped in the last 12 months
Amount in gallons*
Domestic 440,200
Portable Toilet Waste 0
Grease (Restaurant) 0
Treatment Plant 0
Industrial/Commercial 0
North Carolina counties of operation
List each county you plan to do business in:
davidson
Vehicle Info
Do you plan to operate pumper vehicles?*
• Yes No
"I certify, under penalty of law, that the pumper vehicle or vehicles listed in the submitted permit application meets the requirements for safe
and sanitary transportation of septage as required by 15A NCAC 13B .0835(a) and vehicle lettering as required by 15A NCAC .0835(b).
Furthermore, I also certify that a log is maintained of each septage pumping event as required by 15A NCAC 13B .0836(a). I am aware that
there significant penalties for false certification including the possibility of fine and imprisonment."
Signature
Date*
12/6/2022
Title*
owner
Choose how to add vehicle descriptions*
• Add vehicles individually Upload List
Pumper Vehicles
Usage* License Tag #* Vehicle Identification #* Tank Capacity*

Domestic Septage ya119344 lhtscaanxsh686233
Domestic Septage ya119343 lhtscaan8lh378377
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Approved wastewater treatment plant*
• Yes No
If yes, list the facilities below and upload or submit by mail a copy of Wastewater Treatment Authorization for each plant as indicated in
subparagraph .0833(c)(14) of the Septage Management Rules.
Mail forms to:
NC DEQ
Division of Waste Management - Solid Waste Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Wasterwater Treatment Facility Name*
lexington Regional
Septage Land Application Sites (SLAS)
Yes • No
Septage Detention or Treatment Facility (SDTF)
Yes •D No
Other disposal method*
Yes • No
Expiration Date* Authorization
12/31/2023
Septage Management Firm Operator Training Completed
Date* Hours*
3/17/2022 4
Location*
Clemons n.c.
Training Sponsored or Provided by*
NC Septic Tank Association
Septage Land Application Site Operator Training Completed
Date Hours
0
Location
Training Sponsored or Provided by
Registration Type ^

Select one*
Registered Portable Sanitation Firm
• Registered Septage Management Firm
Registered Portable Sanitation and Septage Management Firm
Comments and Notes
Comments or notes
Certif cation Statement
I certify that the information and representations in this application for a permit are true, complete, and accurate to the best of my knowledge and belief. I am aware that a
permit may be suspended or revoked upon a finding that its issuance was based upon incorrect or inadequate information that materially affected the decision to issue
the permit and that there are criminal penalties for knowingly making a false statement, representation, or certification.
Signature
Date
12/6/2022
11:09:56 AM
Print Name* Title*
Joel ketcham owner

AUTHORIZATION TO DISCHARGE SEPTAGE TO A WASTEWATER TREATMENT FACILITY
North Carolina Department of Environmental Quality
Division of Waste Management - Solid Waste Section
1646 Mail Service Center, Raleigh, NC 27699-1646
Fee assessments and waste determinations will be required at the discretion of the wastewater
treatment facility. The facility has the ultimate prerogative to deny discharges of any wastes to the
incoming wastewater stream.
(Plant Operator In Responsible Charge (ORC), License Num ,Name of Plant) W 3
Qg e-%+ � � �-t-i� + Can c_CCt�� N Q-
Qj (Address)
��/� _ QI►�1 3� � " � 6_ @ / P� o hereby authorize (Phone Number) (v�v�er O erator of Septage Management Firm)
/ p
of
(Se tage Management Firm Name and NCS number)
to dispose of: domestic septage portable toilet waste
grease septage (grease trap pumpings) commercial/industrial septage , from
!1 d S Or1ti CA -
(County or oth J Geographic Are )
at the above named wastewater treatment facility. Septage shall be discharged at:
41
between the hours of
Reintroducing partially treated liquid into a grease trap is acceptable Yes ,�No
This authorization shall be valid until l� 31! 205� 3
(Usually December 31, Year)
I � �
Signed 2�
}' _ l t „-Q- Date
(Facility Operator)
Subscribed and affirmed before me this
day of (�%Q,m )o�-CrN
My Commission expires: 04_.-6 -c 9,0a'-7
(Notary Public)
Jamie FreerriORFICIAL S EAL)
Notary Public
Davidson Cow- K
Note; Falsification of this document by the septage management firm shall lead to permit revocation.
5:/Solid_Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/WWTP Authorization Form 2018

North Carolina Department of Environmental Quality
P
Division of Waste Management INVOICE
enNORonmeTH cna¢/¢nrt7i ."A
virSolid Waste Section
Division of Waste Management
Solid Waste Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Phone/Fax: [phone]
Email: [e-mail]
Septage - Annual:
Ketcham Septic Tank (NCS-00167)
PO Box 1223
Welcome, NC 27374
Number of Trucks: 2
P
CK. NO.
DATE_
3 F —&—&6. op
To: Joel Ketcham
Ketcham Septic Tank
PO Box 1223
Welcome, NC 27374
Date: 09/27/2022
Invoice #: NCS-00167-2023
':11 11
Date Due: 1 12/15/2022
LATE FEES: In accordance with NC General Statutes GS 130A-291.1(e2), a late fee will be applied to any annual permit fees not submitted by January 1, 2023.
Payment Options:
E-check Available online at https://deq.nc-gov/`swpaay
Requires bank account and routing information. You will need to use the zip code in the description box and the invoice number
shown on this invoice to access your account. If a zip code is not listed, use the code: 99999 along with the invoice number.
Credit Card Available online at https://deq.nc.gov/swpaY
Accepts MasterCard, Visa, and Discover cards. You will need to use the zip code in the description box and the invoice number shown
on this invoice to access your account. If a zip code is not listed, use the code: 99999 along with the invoice number.
[*Convenience Fee of 2-65% added to amount invoiced.]
Paper check Make checks payable to N.C. Division of Waste Management, Solid Waste Section, include Permit Number and invoice number on
check_ If you are paying by electronic transfer, include the invoice number with your electronic transfer_ Please return a copy of this
invoice with your payment.
[G.S. 25-3-506: A $25.00 processing fee will be charged on all returned checks.]
Explanation of Invoice Amount is Based on Firm's Current Permit Status:
Pursuant to North Carolina General Statute 130A-291.1 you are required to pay fee(s) based on your solid waste management
activities. The fee(s) shall be used to support the septage management program_
For questions regarding:
Billing
Regulations or Technical Assistance
Jared Wilson [phone]
Chester Cobb [phone]
Jeffrey Bullard [phone]
More information available on the web:
North Carolina Department of Environmental Quality (DEQ) - https://deg.nc.gov
North Carolina Solid Waste Program - hUPslldea.nc.;iov aboutdivisions<waste-management,.'solid-waste-section
North Carolina Septage Management Program - htt-s:,'de___�-nc.jov aboutdivisions•waste-mana•aemen- solid -waste -section. special-wastes-and-alternative-
handling/septage