SDTF6304 _APPLICATION_RENEWAL_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 Fa(
1. Applicant
Address
Phone
2. Contact person for site operati n (if different from applicant): % 5 t &," T
Title qLposibon Phone 0 i o 6 ? U - 7 9 702
rn
3. Landowner
Address l c,�� �l� �R� 6 %o-, NIC 2s?zz
P1z P-C/
4. Site Location: County 60re, State Road Nuf9ber 70 (van
Directions to site: 1 w— Tel e4�� L
4 ✓1 I / cM 1L 00 CISI If
J' f Uit (// Li//T
5. Is the location on a permitted Septage Land Application Site?
If yes, give the site permit number here:
6. Indicate whether project is: new renewal modification T L)TF - �3 - v V
For a permit renewal or modification, indicate the existing permit number__LlCS-1AU and the
permit expiration date i?c 31, ZOaLi
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)

Facility Information: the following information shall a 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 V
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 cons ucted or installed (use additional
paper to explain, if n cessary): 5 r� : �! ,'n C/
O Cks w vt 4
Wao � (a w " 9t 1av
5. An explanation of how septage will be discharge in and removed from the facility use
additional PaDer to exp 'n * necessary):
^wivv<
r
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): �/1PA"'10 �c p s`l�„
a,
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 r Treatment
Facility per'
Signature (Signature of company official required) Date
P1,,1:
Print name Title
Note: This application will not be accepted for review until all parts of the application are complete.
S Solid Wastelcla\septagelformslSDTF-Application & AdhorizationlSDTF Permit Application -Jan 2016.docx
ar-1
Rev 01-07-16

ry `
Nc19-�'�
WTHLEHEM CHURCH R
\ o-'
73 M
� � PINEHURST
�TAYLORTOWN
c.41 ylyy NG 211
'Al
us is'S01 M1M�
CARTHAGE � �,i
> WHISPERING
5
K
SOUTHERN 1,714
PINES
Q{ IbU F'eny 12udd
[.. �; I� L 1. �-< � �J (J hti✓r+aende(•,r nynic..rs,
SITE
�
_ � CAMERON
r
- 0ti-
GE
VASS
PINES t
01
Jy to
Antique Town Campground
VICINITY MAP
Moore County, Cameron NC
LEE COUNTY
r`'9/ I HARNETT COUNT
R�
N
DATE
1"= 50,000 Feet

K � y
16
�y'?*` t• Qy: ',1< ' -, t� .e.y '- tip? .•*'
•� R r• p ii �. •`-.. k
.I
b
,
.
�;� V Y/ .. ! I �g�s,�9 �: �, .yc _ . br b1ae"' s•,� ,�;
+Y � •`�� ��• "yw ./, �a .,,. ,�y'",�r+.�?'y 3i •P i �'K.r•, .� 7�t#�'�j., 1 .al if r 1 `� �.� ,�
• ,al Pf` 1 �r �'� ',cam;=�1�-�^ ,� �, � � �•� 'i nq i 'a, ii'��`.`:• �,y�• J .'� r�`� w �/ "� �'" � • ,���' ''.
• �' H i • w[ +� �ytibf `A � '• rf � 1 i M 1 ^� b Z' ^ d • i .. '
Y Yr
!j ixn.� , '�'4, d�) E` , i ,firtow
h
+.•yip �.' ✓��',� vy`�i",t% S.•'M i �T �f Y 4N w i" ! r •.�r , 'C �i "•
'',�yIT. ar•Ai• f 'y
4'`" �'+��' 0'r'A,^.' �%c.. :+' � '' fisnT,;'vt �; `' � a . . ' �^ S rr��,, y` It 'R �; r i+• � b a �� `
� ��ytyi .• r w i ., ee ty �y
.,'• I '�� � � � �� HI, Yy���VM1'�t ���f: �(. �:� �iY 1ra1„*'r�,),, •'e, 7 �• ,�� jY r \.
� S } uf � a .'�"�"7�'' lA >Mti 1T7; j, - r ",Y'.r4 �,�N � � � p��V'7 � :' y l �� •'�" � • .. '1 d�� b
"y�®i1��t� �•yy(�y. �'' 'd;M f �, Iv'. ty/y4'��' �'�, � ";�' '. ,�r�,� s. �w` / �'�,�� - ,.
�� Ir -�Yp igr'��o ir�,� cry `r�' ac,' �•y �11x-I�y' a'y�,y 4/iT �w_ 1 "M.~ `'a, �
�,� • ! -y � w �'� �'.' Ifi ,�' Y r�e- •� � �+c-L��°' ••f 1-`:Y r+ ` Y � r'•' 'r •e��,/
'�' �,� .,,I� y; J „wr,p ;•,� + j' � @'Jd , rA � d' ,t , �I � r � �'.,' r' tii .

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
1, I �
Lr-4 1 -1 S (name of site owner) hereby certify that I am the owner of
5 J acres of land located 170 n - 0y o c-✓�, Un%l and
identified by 3 3 3 ;!35 (book and page of recorded deed or tax map parcel) and
that I agree to allow In 70-,M �% LC (131�1 DTF permit applicant) to use
said land for a septage detention or treatment facility for aperiod of rn4e-t.,, &1 (length
�7
of time), beginning C-1 _ o/ J (give date) and that I have read the North Carolina
Septage Management Rules *. I further understand that no septage may be stored or treated on the land
until the Division of Waste Management has issued a permit for a detention or treatment facility. The above
described property is owned solely by me or jointly with mIli h,
1',17 S. (names of ail co -owners, or state none).
Date rl-1.1 6
Signature of landowner Date
Sworn to and subscribed before me this r[G, day of . 20 _.
(OFFICIAL AL
(Notary Public) DENA B SESSOMS
Notary Public, North Carolina
Moore County
My Commission expires: r1 My Commission Expires
February 07, 2026
* 15A N.C. Admin. Code 13B Section .0800
Rev. 01-07-16