SDTF7821_APPLICATION_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 Facility Information
1. Applicant
Address 2 �.�, M•
0
Phone 9111- 7H0-0G9't-
Contact person
Title or position
Address
3. Landowner - m J e fq C "'04w—
Address �.A
4. Site Location: County AaiJek, � State Road Number
Directions tq site: AlwX VJ AA! o j, t � or f y,� , �ej
2 µ,.
5. Is the location on a permitted Septage Land pplication ite?
If yes, give the site permit number here:A
6. Indicate whether project is: new renewal modification
For a permit renewal or modification indicate the existing permit numbe � ,7�- � JJ and the
permit expiration date
-(per ) h o o 0 JCt.A.,
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. !f 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
�ite or wastewater treatment plant to be used after treatment or storage:
W w 7 -P
(over) f wi l'f� �J0�

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(over)
!!. Facility Information: the following information shall be included with the application form.
1. Facility to be used for: Storage Treatment
Grem-TraP-l*p?n9s .
"Talletwade . C=wdaitibdustrid.Sepoge
I Types -of treatment to be prowled pH Adjustment ime stabilizetlonl �%
Screening Off ler(attach explanation -if oilier)
4. A+descriptim Of theproposed, deter►#im or treatment
-_ sty mdudi�:the Ste..
_ r type, and number of
-ShMIun;S to be used and howthosb str iett
.-. ._ sttuctures., con _ nstalletl addWonalpaperfe
" . or
� mouse -
t hereby cei* that:
kt Tf�e #tanriatiop;gro i n, ;�pli ,. c r le MrIMAI .the-bestd-My
r>
2.
-��e;
l have read and understand the NC -
age l Mnagement Rules
#:am ofthe Of t, 11r3tarid�erti# reuceatiororfii!
':..:Itwitimor
.
€at
1,2 1 �
PINname Me
'Signature of company official IWIIed.-
Note; This application wilt not be accepted far review until all parts of the application are complete.

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Landowner's Authorization to Operate a Septage Land Application Site
North Carolina Department of Environment and Natural Resources
Division of Waste Mgement - Raleigholid Waste Section
NC 27699-1646
1646 Mail Service Cener,
i rh : e- C! A , �� ✓- (name of site owner) hereby certify that 1 am the owner of
acres of land located
_ (book and page of recorded deed
and identified by _ � ��e°
or tax map parcel) and that I agree to allow .'►-►�
d gq dP -- (name of site
(length
operator) -td'use said land for septage land application for a period of r0
time); beginning
(month, day and year) and that I have read the
of
strictions on
a MJib, PI., Se age Management
North CRules *, and I understand and agree to maintain the re .
cation ends l further understand that no septage may be land applied
land use after septage land application
of Waste Management has issued a permit for a septage land application site. The above
until the Division
P
ed property is owned solely by me or jointly with
described p p
(names of all co -owners, or state none).
r
Sworn to and subscribed before me this
(Notary Public)
My Commission expires:
* 15AX.C. Adm' in. Code 13 Section .0-800
** As required by Rule .0843
Date &�
day of ! L 20�
or pTAR�
Er.007,111-11
01/1019

QUALITY SEPTIC LLC
On -Site waste water Inspection
Inspector Dotes
Due to health reasons Jimmie L Carter
can not travel to notary we have used the one included
it was for riles mild
.Thanks Jimmie M Carter.
12-10-2022