SDTF5506_APPLICATION_RENEWAL_2024

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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
1. Applicant
Address
Phone
2. Contact person for site operation (if different from applicant):
Title or position _�J�►d Ct�r�;er Phone `7DLI—�1U(�-G I93 C�11
Address
3. Landowner
Address
4. Site Location: County a)I Y> State Road Number.
Directions to site: (0 j-u
Is the location on a permitted Septage Land Application Site? Sl��l—' ss—cam
If yes, give the site permit number here: _
Indicate whether project is: new renewal >/ modification _
For a permit renewal or modification, indicate the existing permit number
permit expiration date
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). If 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 used after treatment or storage:
(over)

Facrlity tnfbrmation: 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 ✓ Grease Trap pumpings
Portable Toilet Waste ConUnerdaWndustrial Septage
3. Types of treatment to be provided; pH Adjustment (lime stabilization)
Screening other (attach explanation if other)
4. A description of the proposed detention or treatment facility, ize, type, and number of
ncluding the si
strictures to be used and how those structures will be constructed or the sLled (u additional
pa r to explain, N nece c T.
5. An explanation of how septage will be discharged into and removed from the facility (use
addition ! paper to explain, if necessa ):
i. .An explanation of how any leaks or spills at the facility will be leaned nd how odors will be
controlled (use addlibloal parer to axnJain K na.o.�- A. �• I - r, r
Ill. Certification
1 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 Detehtion or Treatment
Facility permit.
Si 9� tore - �� 7 (SJgnahseorrAyolfxx�rsq Date — —
Title
Note: This application will not be accepted for review until all parts of the apppca Lion am complete.
S:Solid W-Ae WtagEi ftrms�SDTF-Appicetieo & quthOdetionlSDTF Pertnft ApplicaUo,, an 2016.doac
S! 9••J.vfc -
Rev 01-07-16

Limited Liability Company 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
I hereby certify that the undersigned limited liability company, O LL�owns
a .212 acres of land located %,6 I 5Z�(3 and identified
a — (book and page of recorded deed or tax map parcel)
and that the limi ed liability company agrees to allow o .nturm��.5�, �r tam (SDTF pe it
applicant) to use said land for a septage detention or treatment facility for a period ofV` �-'rsgth
of time) beginning Y arrb'1 i Ao 19 (give date), and that�,J
n behalf of the limited a illy company, I
have read the North Carolina'Septage Management Rules*.rn ec 1-4--h I t ' (name of
limited liability company) further understands that no septage may be stored or treated%ntil the Division of
Waste Management has issued a permit for a detention or treatment facility. The above described property
is owned solely by the undersigned limited liability company, or jointly with �L C� ,n Kn c�
-i (name all co -owners, or state none).
Date: 1
LuvYitr ! b LL
Limited Liability Company (PrA Name)"
re (AutKorized Member or Manager) - Print Name and Title
orth Carolina
t (Nof n County.
a Notary Public for said County and State do hereby certify that
(name of authorized member or manager of limited liability company)
personally appeared before -me this day and, being first duly sworn, acknowledged that he (she) is a (the)
-� (member or manager) of v- s Lt,C, a limited liability
company, an that by authority duly given and as the act of the limited liabilit ompany, the foregoing
instrument was signed in its name by its authorized (member or manager) , and that the
statements contained therein are true. Witness my hand and dfficial seal, this the ��_ day of
-1) Lc.ernbPL- , 20 t
Not ry Public
My Commission expires: _ _0?0Q L
* 15A N.C. Admin. Code 13B Section .0800
(OFFICIAL SEAL)
April M Party
NOTARY PUBLIC
Lincoln County
North Carolina
My Commission Expires I 2026
Rev.01-07-16