SDTF8506_APPLICATION_RENEWAL_2024

�)DTF NC5 # CU45q
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 Phone
Address
3. Landowner J eP 11---&ilk e
Address �W4 l\W. �? Auiu. N.
4. Site Location: County State Road Numbei
Directions t site:y44 'RAJ' e, 6_ iU AW
o l (ow k `North Jo Yfi le � ale on O ine ra
be,!5de La&8mV7i e ee. /a ml , 4 ea Hishfon Ha
5. Is the location on a permitted Septage Laro ApplicationSite?
If yes, give the site permit number here: 25 0
1 JAq
I . lla-# �e Wh d r ire
119! o--n Ief-+ -�o 5ife,
6. Indicate whether project is: new renewal modification
For a permit renewal or modification indicate the existing permit number,'S�TF and the
permit expiration date
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 Lability 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)
OLd euve,
IN

II. Facility Information: the foilowing 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 I Grease Trap Pumpings
Portable Toilet Waste Commercial/Industrial Septage
I 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 c onst or installed (use additional
paper to ex ain, if ecessary): Ion j ->f
r-)M IWI ` hP?a,c ) n rn tI P I AVP
5. An explanation of how septage will be discharged into and remoypd from the facility (use
additional paper two eCxpiain, if necessary): � D
6. An explanation of how any leaks or spills at the facility will be eaned and how odors will be
controlled (use add'rtlonal paper to explain, if necessary): � i I t5
�Aiill1 b r
WI( +1-0
i do6jj a0d LA6i i fl
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.
1 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 permit. i
1 ()"31-�i
Slg Signature of company oihaat r+ gquk4 Date
J � �r� [rr
Print name Title
Note: This application will not be accepted for review until all parts of the application are complete.
S:Solid Wasteldalseptagelforms%SDTF-Application & Author¢ation\SDTF Permit Application -Jan 2016.docx
Rev 01-07-16

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P-TI4: bVg3gr7000
C467
LandoWnees Autharizaijoh to Operate a Septage Detention or
'treatment Facility
North Carolina Department of 8nrironmental Quality
CiMsion..nf Waste -Management ;. Solid Waste- Section
'1646 Mail Service: Center,--RaleIg ' NC 27699-1646 .
l; ltimmte `(;Q yin c} r?. (:table dfsfte owner) hereby certifjr that I am the owner of
acres of land located ;��nvi I )� 'and -
identified by ejQ(>}( c9a6.url Pa0g. Tjr]- - ,( and page of recorded deed or tax map parcel) and
: �
that I agreeto allow. ' ' - dtk- `�70 :. �p� -
-(SDT1= permit applicant) to use
said land for a septage detorrtiari or treairrreri facility for- a period of J (length
Of time), beginning Q7 c� p"� (give date) and that I have read the Forth Carolina
Septage Management Rules *. I further understand that no se
ptage may be stored or treated on the land
until the Division of Waste lUlanagement..l�as issi�etl aE perchitfor a deteiatierr" or t a#m6nt facility:.1he-.above
described property is ownedsoleljr by. me or jointly with %i SIG
(names of all co-
owners, or state none .
-- )
,S(unftre of landowner Date
Qrratun= of landowner Date �� �' LQ f
Rriature of landowner Date
Swann to and subscribed before me this day of -� 20
(Notary Public) (OAF J 1E L STOWE
OTARY PUBLIC
iwty Commission expires: O J 2,0 744
16A N.C. Admin. Code 13B Section .osoa
. N
STOKES COUNTY
NORTH CARfy
My Commlasion Ex , () L�
Rev. 01-07-46