SDTF-18-05_RENEWAL_APPLICATION_2024

Application approved 8/16/2024
Stephanie Williams
APPLICATION FOR A PERMIT TO OPERATE A SEPTACE 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 Facility Information
1. ApplicantC®o1 PO-rk PUMPinr4 -7y]r -
Address u 14 '1 1-In
2.
Phone
Contact person for site o
Title or position 0Q 2
Address 19 �5
3. Landowner
Address
LLC
4. Site Location: CountyIState Road Number d
Directions to site: -= tio EA a -� L Orrin �.l
i -
5. Is the location on a permitted Septage Land Application Site? NQ
If yes, give the site permit number here:
a
Indicate whether project is: new renewal modification
For a permit renewal or modification, indicate the existing permit number,
permit expiration date 14- � -7 - Q o 14 .
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 lard use a corporate landowner authorization form. If Limited Liability
Company owns the land, use a limited liability company landowner authorization form.
M
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:
J�F- 3� - �5
.(oven

Facility Information: the following information shall be included with the application form.
1. Facility to be used for: Storage. 1/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) V-11"
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): 9 Mp a J D ®, ppt)-V— �OJ D ph - any
5
An explanation of how septage will be discharged into and removed from the facility (use
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): GQ
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
Facili ermit.
.A"y�" ' ✓ • d2 q
ign (Signature of company official required) date
�S o APB
Print nanfe Title
Mote: This application will not be accepted for review until all parts of the application are complete.
S:Solid_Waste\cla\septage\forms\SDTF-Application & Authorization\SDTF Permit Application -Jan 2016.docx
Rev 01-07-16

Limited Liability Company 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 hereby certify that the undersigned limited liability com
_ . acres of land located 111�1 j.,�nM s I I
and identified
by .L�ccK dgcr t YC�1F % l aq book and page of recorded deed or tax map parcel)
and that the limited liability company agrees to allow Or N�C I (SDTF permit
applicant) to use said land for a septage detention or treatment facility for a period of Its t rs (length
of time) beginning y- I9 -c)t (give date), and that on behalf of the limited liability company, I
have read the North Carolina Septage Management Rules*. C (name of
limited liability company) further understands that no septage ma be stored or treated until the Division of
Waste Management has issued a permit for a detention or treatment facility. The ab described property
is owned solely by the undersigned limited liability company, or jointly with 41
v
(name all co -owners, or state none).
Datka �:�
e 1, 4 w- e') i /--ram
Limited Liability Com any (rint Na e)
(Authorized Member or Manager) Print Name and Title
North Carolina
County
Pfk& " 6 , a Notary Public for said County and State do hereby certify that
(name of authorized member or manager of limited liability company)
personallyAppeared before me this day and, being first duly sworn, acknowledged that hZed
) is a (the)
ryym,6} _(member or manager) of ('� 0r C liability
company, and that by authority duly given and as the a of the limited ability company, the foregoing
instrument was signed in its name by its authorized (member or manager)j and that the
?ments contained therein are true. Witness my hand and official seal, this the day of
ruX0- , 20-,,2_.
Q--�O Z (OFFICIAL SEAL)
Notary Public r
My Commission expires��3 G
* 15A N.C. Admin. Code 13B Section .0800
Rev. 01-07-16