SLAS8506_APPLICATION_RENEWAL_2024

L A � oD467
-- - APPWChTION FOR A PERMIT TO OPERATE A SEPTAGE•L-AND APPLICATION SITE - - - -
North Carolina Department of Environmental Quality
Division of Waste Management - Solid Waste Section
1646 Mail Service Center, Raleigh, NC 27699-1646
Site and Operator
1. Applicant
Address
Phone
2. Contact person for site operation (if different from applicant):
Title or position Phone
Address
3. Landowner
Address
4. Site Location:. County 'State Road:Number 14qc
Directions tosite'+D ins n 2.- 10e.5a N +o tin 2�+ (-olloc
B 1`,rah +o Yi �n. a, e an6 . v w-�� d. a+"
ri g e Ice, 90 ya m�1e 4r�en +ake ci, ,g /on � qf� drive,
5. Indicatewhether`requestis: new renewal v ' modification- af In [eP* +o
5' 4e-
For a permit renewal or modific ifion," ro -de the following information:
Existing site permit number. -D& permit expiration date:Jan- _ pa,
6. Number of acres meeting the requirements'of the N.C. Septage Management Rules: 31 acres.
7. Substances o r than septage or grease trap pumpings previously disposed of on the site:
(a) None. , or (b) Attach a list indicating other substances, the amounts discharged,
and the dates ddischarge.
B. Attach written, notarized landowner authotization.to operate a septage disposal site signed by the
landowner (if the permit applicant does -lot -ow the -property)- lf-a corporation°pwns the land
use a corporate landowner authorization fonr .'If Umited Liability'Company owns the land,
use a limited liability company landowner authorization Join.
9. Attach site evaluation report, including aerial photograph and soil analysis with metals results,
unless the Division prepared the report.
10. Attach a vicinity map (county road map showing site location).
(over)

Site. Management Information:
1. The following information shall be included With the application form:
(a) Nutrient Management Plan .
(b) Soil Erosion and Runoff Control Plan
2. Alternative plan for dis oral (detention facility permit number or wastewater treatment plant.
authorization): �-
3. Types of septage proposed to be discharged at the site (chat all that apply):
(a) Domestic septage pumped from septic tanks
(b) grease trap pumpings
(c) Portable toilet waste
(d) Commercial / industrial septage
4. Proposed treatment thud of each type of septage to be land applied use additional paDer to
explain if necessary): 0 %Cif^a. j im t'Q 5� N +o
5. Proposed method of applying septage to
add�ionaIpper to explain if necessary):
rv] iH k
including septage distribution plan if required * (use
6. Demonstration - T the appropriate, state or federal government -agency that the land application
site complies with the Endangered Species Law ** or if any part of site:specified is not
ricultural i d, use additional a r toe lain rf necessa f
III: Certification
hereby certify that:
1. The information provided on this application is true, complete, and correct -to the best of my
knowledge.
:. I have red, and understand the N.C. Septage Manageement.Ruies, and
- -- 3.-1 am _aware of the potential consequences, -including -penalties and -p.ermft revocation, for failing
1-Jbilowalf, licable.rules and the conditions of a Septage Land Application Site' it,
�.D:- 3 33
$I ofmnpanya"re%mo pate —
Je Lao 6Dn
Print name title
Note: This application will not be reviewied'until all Paris of the application are complete.
* Refer to Section .0837(e) of the N.C. Septa" Management Rules.
** Refer to Section .0837(g) of the N.C. Septage Management Rules.
S:Solid WasteldalseftelformslsLAs Application & AuthorizationlSLAS Permit Application -Jan 2016.docx
Rev 01-07-16

6LA� 4:�- 76-662
IVC� #- D045`7
Landowner's Authorization to Operate a Septage Land Application Site
North Carolina Department of Environmental Quality
Division of Waste Management - Solid Waste Section
1646 Mail Service Center, Raleigh, NC 27699-1646
I, ( nile LQ. tLto ( ' (name of site owner) hereby certify that I am the owner of
3, acres of land located _ 1410 rl H art Rd • Lduj L 0 \/I I (ems �1 C and
identified by (3DDLa 3, O d S T7 (book and page of recorded deed or tax map
j
parcel) and that I agree to allow �e L(,tw�bf) (site operator name) to use said land for
septage land application for a period of 5 r (length of time), beginning J Oil . I. (give
date) and that I have read the North Carolina Septage Management Rules *, and I understand and agree to
maintain the restrictions on land use after septage land application ends ". I further understand that no septage
may be land applied until the Division of Waste Management has issued a permit for a septage land application
site. The above described property is owned solely by me or jointly with _ I t
Sworn to and subscribed before me this "
�Itli - ); kk9--
(Notary Public)
My.Commission expires: r2
* 15A N.C. Admin. Code.13B Section .0800
** As required by Rule .0843
___ _ (names of all co -owners, or state none).
day of Ozte.AQ/ , 20�_.
JJ MELSTOWE
NOTARY PUBLIC
STOKES COUNTY
LI c
L 00
Rev. 01-07-16

Meld �
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SEPTAGE LAND APPLICATION LOG
CERTIFICATION
Site Operator: Jet--P Law/30
SLAS Permit #: 7 6 - 0t o
Site Location: 1411 )-iQJ 4 13d. ( puttmil le.
(street address for the site or latitude and longitude)
Number of acres permitted:
Permitted application rate: 50. QDb
(gallons septage per acre per year)
Crop(s): ae, Aerm DAAnr Qec
Crop nitrogen requirement(s): 1b
(pounds nitrogen per acre)
CERTIFICATION:
"1 certify, under penalty of law, that the pathogen requirements in (insert either
503.32 (c)(1) or 503.32 (c)(2)) and the vector attraction reduction requirements in
(insert 503.33 (b)(9), 503..33 (b)(10) or 503.33 (b)(12)) have been met. This
determination has been made -under my direction'and supervision in accordance
with the system designed to ensure that qualified personnel property gather and
evaluate the information used to determine that the pathogen requirements and
vector attraction. reduction requirements have been met. I am aware that there
are significant penalties for false certification including the possibility of fine and
tmpr sonmen/tt."
J Wignature) (date)
S:ISolid WastelclalsepiagelformslSLAS-Application & Authorization%2011 SLAS Log.doc

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