SDTF9601_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
1. Applicant
Address
Phone `i19 - --Y?S;-a t-Q / ,iI - 73!:e - 5
2. Contact person for site operation (if different from applicant): hr j s Fa;.- k—s
Title or position 01,Wn 4 x - Phone 9 ice( - --7-7--!r c, zc, �( tri
Address 11\ii - ►3 Pot,KSi-A"-)T-,
3. Landowner
Address
Site Location: County _L&L
Directions to site: &,; "10
,t2�1 k I /a- M,
1?A
5. Is the location on a permitted Septage Land Application Site?
If yes, give the site permit number here:
0
Indicate whether project is: new ✓ renewal modification _
For a permit renewal or modification, indicate the existing permit number.
permit expiration date I':A • '20 - G` 3
and the
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)

II. Facility Information: the following information shall be included with the application form.
1. Facility to be used for: Storage ,,i Treatment
2. Types of septage to be stored or treated:
Domestic Septage ✓ 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): If it v I --- t� t, , ; y�
q gV Z Si Cx7� Oct
5. An explanation of how septage will be discharged into and removed from the facility (use
ad/d�itionajl patyper}/lr
t�o explaiLn, if necessary): :/Fev►v I r,'c-k �re� �
— u.k 05�
An explanation of how any leaks or spills at the facility will be cleaned and how odors will be
Ill. 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 permit.
Signature (Signature of company official required) Date
Print name Title
Note: This application will not be accepted for review until all parts of the application are complete.
S:Sol id_Waste\cla\septage\forms\SDTF-Application & Authorization\SDTF Permit Application -Jan 2016.docx
Rev 01-07-16

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
I, 4,1L L LAII t (n me of site owner) hereby certify that I am the owner of
41 acres of land loca and
identified by (book and page of recorded deedVtax map parcel) and
that I agree to allow LP &i5 (SDTF permit applicant) to use
said land for a septage detention or treatment facility for a period of (length
of time), beginning �i>!L1�1 f �7. give date) and that I hav r ad the North Carolina
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 ow-4(-
(names of all co -owners, or s. none).
Signature of landowner
Date
Sworn to and subscribed before me this day of
C4 20.
(OFFICIAL SEAL
(Notary Public)
_ o o z
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My Commission expires: — =�
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15A N.C. Admin. Code 13B Section .0800
1Nf11
Rev. 01-07-16

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W + E SDTF-96-01 located in Wayne County off of SR 1714.
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crc, Jan. 2011