SDTF6714_APPLICATION_MODIFY_2024

APPLICATION FOR A PERMIT TO OPERATE A SEPTAGE DETENTION OR
TREATMENT FACILITY
North Carolina Department of Environmental Quality
Division of Waste Management - Solid Waste Section
1646 Mail Service Center, Raleigh, NC 27699-1646
Operator and Fa(
1. Applicant
Address
Phone
2. Contact person for site operation (if different from applicant): t�-e-
Title or position Phone C-9r 3 3 'e> _ a
Address a.o —3 :AP — o
3. Landowner Y v`eAvi 1 1� 3v �"
Address 'L-45
4. Site Location: Co my State Road Number (`f
Directions to site: - S'^
5. Is the location on a permitted Septage Land Application Site?
If yes, give the site permit number here:
Indicate whether project is: new renewal ✓ modification 5 ��
For a permit renewal or odification, indicate the existing permit number S �
permit expiration date CA - a ; .
�-I- u '
� 7 1 q
and the
7. Attach written, notarized landowner authorization to operate a septage storage or treatment facility
form signed by the landowner (if the permit applicant does not solely own the property). /f a
corporation owns the land use a corporate landowner authorization form. If Limited Liability
Company owns the land, use a limited liability company landowner authorization form.
8. Aerial photograph scale 1 inch = 400 feet with site property lines accurately located on the photograph
must be enclosed (if 1 inch = 400 feet is not available,1 inch = 660 feet may be substituted).
9. Vicinity map (county road map showing site location).��-
10. Land application site or wastewater treatment plant to be ysed after treatment or storage:
Ust,�C.� o :� I Cra i zsy-\ 1-7 i9 -�S—
(over)

Facility Information: the following information shall be included with the application form.
1. Facility to be used for: Storage ✓ - Treatment
2. Types of septage to be stored or treated:
Domestic Septage V"" Grease Trap Pumpings ✓
Portable Toilet Waste _v-"- Commercial/Industrial Septage
3. Types of treatment to be provided: pH Adjustment (lime stabilization) Z
Screening Other (attach explanation if other)
4. A description of the proposed detention or treatment facility including the size, type, and number of
structures to be used and how those structures will be constructed or installed (use additional
pa -par to explain, if necessarry�): -2 1-5 - '+Cbt> °- I- 5-6n -ko�,A S
J"t-C
5. An explanation of how septage will be discharged into and removed from the facility (use
additional paper to explain, if necessary): � k y s�,,
6.
III. Certification
I hereby certify that:
1. The information provided on this application is true, complete, and correct to the best of my
knowledge, and
2. 1 have read and understand the N.C. Septage Management Rules.
3. 1 am aware of the potential consequences, including penalties and permit revocation, for
failing to follow all applicable rules and the conditions of a Septage Detention or Treatment
&�Ipermit.
Signature (signature of company la1 req m1,' Date
Print name Title
Note: This application will not be accepted for review until all parts of the application are complete.
S:Solid Waste\cla\septage\forms\SDTF-Application & Authorization\SDTF Permit Application -Jan 2016.docx
Rev 01-07-16

SDTF-67-05 & SDTF-67-14
Landowner's Authorization to Operate a Septage Detention or
Treatment Facility
North Carolina Department of Environmental Quality
Division of Waste Management - Solid Waste Section
1646 Mail Service Center, Raleigh, NC 27699-1646
John Melville (name of site owner) hereby certify that I am the owner of
24.4 acres of land located 4 miles SE of Belgrade behind 2018 Belgrade-Swansboro Road and
identified by Book 60801 Page 0235 Tax ID # 1143-17.3 (book and page of recorded deed or tax map parcel) and
that I agree to allow
Atlantic All Pro Septic Tank Service Inc.
(SDTF permit applicant) to use
said land for a septage detention or treatment facility for a period of . `j - caul S (length
of time), beginning 1J ck 1N 1- 9 'T (give date) and that I have read the North Carolina
Septage Management Rules *. I further understand that no septage may be stored or treated on the land
until the Division of Waste Management has issued a permit for a detention or treatment facility. The above
described property is owned solely by me or jointly with
of landowner
none
(names of all co -owners, or state none).
Si nature of landowner V Date
Signature of landowner bate
Sworn to and subscribed before me this day of 4n y1'
1 20_.
do 106
(Notary Public)
My Commission expires:
* 15A N.C. Admin. Code 13B Section .0800
(OFFICIAL SEAL)
1 MELISSA JACOBS
NOTARY PUBLIC
Onslow County
North Carolina
.My Commission Ex.pines June 10, 2027
DECEIVED
APR 2 9 2024
Rev. 01-07-16
SOLID WASTE SECTION

AUTHORIZATION TO DISCHARGE SEPTAGE AT A SEPTAGE TREATMENT OR
STORAGE FACILITY PERMITTED TO SOMEONE OTHER THAN YOURSELF
(This form is used by a detention or treatment facility permit holder to indicate that permission
has been given to a permitted Septage Management Firm to discharge septage into the permit
holders detention or treatment facility.)
31:�
(Facility Operator)
- l�1rn'��rJ�� �•
(Operator Address)
do hereby authorize: _ ` ft xe, V �
(Owner of Septage Management Firm)
a C'Tsl�
—A�E � i---_�C_ &A \ !� t( u S 4�-a'CNCS # C_ 1
e'�-AD"Ir to Iiaj5rAtftjirm)
of Septage Management Firm)
"E Zoq -©s--
to utilize septage detention or treatment facility #SI1 F 0-1 � for the treatment or storage of
septage *
in 20 oZ `� The facility will be operated in accordance with the Septage Management Rules **.
� 2
Date: Signed
(Facility Operator)
* As defined in G.S. 130A-290(a)(32)
** As defined in 15A NCAC 13B .0800
Return the properly completed form to:
North Carolina Department of Environmental Quality
Division of Waste Management
Solid Waste Section
1646 Mail Service Center
Raleigh, NC 27699-1646