SDTF4503_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 Fnrifiht Infnrmo►;—
Applicant
Address
Phone
2. Contact person for site operation
Title or position t-6 aA
Address // 4n 1. c
3. Landowner
Address
different from applicant): --t
Phone
AI , lq" clst A
4. Site Location: County 11,Z,/-
aG/e,r.s'n A) _ State Road Number
Directions to site: , f 4ry aft' �t .,_ q.,. ,, li ,A,..
5. Is the location on a permitted Septage Land Application Site? N'v
If yes, give the site permit number here:
1,7'AN
6. Indicate whether project is: new renewal V modification
For a permit renewal or mod'filcatio in irate the existing permit numbers rFF b and thepermit expiration date' / �, 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). 1f a
corporation owns the land use a corporate landowner authorization form. ff Limited Liability
Company owns the land, use a limited liability company landowner authorization form.
01
B. 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)

II. Facility Information: the following 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 Grease Trap Pumpings
Portable Toilet Wastes Commercial/Industrial Septage
3. Types of treatment to be provided: pH Adjustment (lime stabilization) H'/A
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): / �i' n e,,^��� / �ccc/eel
Lf"nfQ g-H_ -�/t K 1/iS"% Jib-J U-e7aey
5. An explanation of how septage will be discharged into and removed from the facility
additional paper to explain, if necessary): /3 late ryc �� e» �,, e
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 nec^essary):1wnK �s SPAled
I
q-5 1 0, Cl-e-d O
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
faili follow all applicable rules and the conditions of a Septage Detention or Treatment
Fa �Rermit.
1 t-s A
Signature (Signature of company official required)
Date
_/-)6ZY,S-Ass. /! M g,1 r e A
Print name Title
Note: This application will not be accepted for review until all parts of the application are complete.
S:Solid_Waste\clalseptagelforrns\SDTF-Application & AUthorization\SDTF Permit Application -Jan 2016.docx
Rev 01-07-16