SDTF7907_APPLICATION_INITIAL_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 G) " (N &G` ( cv-'Kx c- --Krsr t*-- tnwftlq
Address I`'lC� (F
Phone -L
2. Contact person for site operation (if different from applicant): (-=)cAZYL K bs (- -
Title or position �a - o OJ NOETZ Phone 3 Cp -3 y'L-- 0Le 0
Address t_`� 4 0 nrlrfi1 I(I'-p.
3. Landowner 5106S Y"K-SSVGi
Address i k4 P wars Q-�7 .
U't--.css .r\ t--� L 213-7:0
4. Site Location: County &ckuN&ktfq\/\ State Road Number 00
Directions to site: t6S-'1ry - D u.le�
M\-LPiiL� cth"- -\-Mc-C LGV-T art Q C"
5. Is the location on a permitted Septage Land Application Site?
If yes, give the site permit number here: `1 - aZ
6. Indicate whether project is: new renewal modification
For a permit renewal or modification, indicate the existing permit number "7 - 0 2 and the
permit expiration date JM- Ny*-g�I. 3©F Zo 2S
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 used after treatment or storage:
i Q ct-1 S CIA or—(Z
(over)

II. Facility Information: the following information shall be included with the application form.
1. Facility to be used for: Storage [f' Treatment ✓
2. Types of septage to be stored or treated:
Domestic Septage t,,"" Grease Trap Pumpings
Portable Toilet Waste Commercial/Industrial 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 including the size, type, and number of
structures to be used and how those structures will be constructed or installed (use additional
paper to explain, if necessary): Z rn � E-&�• S
5. An explanation of how septage will be discharged into and removed from the facility (use
additional paper to explain, if necessary): S jEf-cfre;>v b tscrNj ` t N"T-p
-t sr`c , �• P ��M4 �l (zcYv`y—g'L Qtrnnp
F� t'FfZ v�Pcb i 72-C-tV-r-r.n0-~n r YcT; i t_t 2� `
6. An explanation of how any leaks or spills at the facility will be cleaned and how odors will be
controlled (use additional paper to explain, if necessary): So t.L-S \ i\AIAGy( !
L VP W lriN`� P t4
i
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
Facility ermit.
gnatb re (signature corn+ ny official required) Date
&C' - LL'\N&6()N [l Co - OWN9Y2- _ ___--
Print name Title
Note: This application will not be accepted for review until all parts of the application are complete.
S:Solid Waste\cia\septage\forms\SDTF-Application & Authorization\SDTF Permit Application -Jan 2016.docx
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
IJL_L
I hereby certify that the undersigned limited I' bility company, &"it rb L-19f s 'oc owns
_ acres of land located 7mkVXVc Vc. ?CN>s ao- and identified
by (book and page of recorded deed or tax map parcel)
and that the limited liability company agrees to allow c � gkLL; n3&s �c`( « (SDTI= permit
applicant) to use said la d fo a septage detention or treatment facility for a period of % D `i �'�ength
of time) beginning � Il 2oz (give date), and that on behalf of the limited liability com any, I
have read the North Carolina Septage Management Rules*. F)ika I.r,�Bgscg L name of
limited liability company) further understands that no septage may be stored or treated until 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 Kt.;, t,�
(name all co -owners, or state none).
Date: 9 ' / -9 9
ASS oe_a - I
Li mi d Liability Company rint Name)
Signature (Authorized Member or Manager) Print Name and Title
North Carolina
c-V-k,SC, County
I, 6 w<, C, l kkAi�s , a Notary Public for said County and State do hereby certify that
rr a (name of authorized member or manager of limited liability company)
personally appeared before me this day and, being first duly swom, acknowledged that he (she) is a (the)
111 etwb*,., (member or manager) of &A*A • lam u 5 , a limited liability
company, and that by authority duly given and as the - act of the limited liability company, the foregoing
instrument was signed in its name by its authorized 'lemher (member or manager) , and that the
s tements contained therein are true. Witness my hand and official seal, this the Y r day of
20
A VIC4 �F
LL ,
AT E Q.1,'
Notary Public ,, AA ��•• - %'
My Commission expires:7���
p': pUB00 :
* 15A N.C. Admin. Code 13B Section .0800 '•, GNAM OOJ
Rev. 01-07-16