SDTF7818_APPLICATION_RENEWAL_2024

APPLICATION FOR A PERMIT TO OPERATE A SEPTAGE ]DETENTION OR
TREATMENT FACILITY
North Carotins Department of Environmental Quality
Division of Waste Manaaemmnt— Solid Waste Section
1646 Mail Service Center, Rareigh, NC 27699-1646
Operator and Fa
1. Applicant
Address
Phone
2. Contact person for site operation (if different from applicant?: --fLAJVJa
Title 4r posilion _ 3 Ull t� i _Y Phone :5 ALE �
ess Addr�---
3. Landov.ner
Address
4. Site Location: County
Directions to site:
Slate Road Humber OLR
5. Is the location on a permitted Septage Land Application Site? If yes, give the site permit number here:
G. Indicate whether project W new_ renewal Z_ modification _
For a permit renewal or modification, irEdicale the existing permit number5rrr --33- t R and the
permitexpimlion date
'- 7. Attacb written, notarized landowner authorizagon to operate a septage storage or treatment facility
form signed by the landowner (it me permit applicant does not sorely own the property), 1f e
corporation owns Me farad use a corporate landowner autholitation form, tfLimited Liability
�+ Company owns the land, use a llm[W fiabik company landowner aothoriza6an form.
$. Aerial photograph scale 1 inch = 400 feet with site property lines accurately located on the photograph
roust be enclosed (if It inch = 400 feet is no; avaiiabfe. ? inch = 660 feet may has substituted),
g. Vicinity map (county road map showing site location),
k0. Land application site or wastewater t;•eatmenf plant to be used after treatment or storage:
(over) ---

11. Facility Information_ the following information shall be included with fhe application form.
1. Facility to be used for, Storage v ...._ Treatment_ �
Z. Types of septage to be stored or healed:
Domestic Septage ./ Grease Trap Pumpings to, Ly�I
Portable Toilet Waste CommerdalAndustrial Septage —v P
I 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 is be used and howttrose structures will be constructed or installed (use additional
papertoexplabb ff necessary)- cin l G[3C]c�cz(fry�� 4nr,k
5. An explanation of how septage will be discharge into and-nernoved from the facility (use
additional paper to explain, iifnecessary). war
_
.,_
6. An explanation a' how any leaks or splits attire facility will be cleaned and how odors will be �td5
controlled (use additional paper to explain, if necessary: -�� jl rr
u1�tCry4 IBC tl �i _i a �.e�c! r�# r c.L+xtM U11+6
uc, ti r cWVAr% Up avp/
tj - - . 1 `' -F . t L�
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Ceritification - *v- Lecr k
l hereby certify that:
I. Tho 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 Managerngnt Rules.
3. r am aware of the potential consequences, including penalties and permit revocation, for
failing to follow all applicable rules ard the conditions of a Septage Detention or Treatment
Facility permit.
j!�`a....
Sfgnaturle fS4najU.ra 0rcarnpanyZdAakfrn4ud..Be) Date
r� I _ —.,o ,trr _._._._._.._._ ; _....
Print name Title -
Note: This application will not be accepted for review until all parts of the application are complete.
S:SOIi fNaste{olaiseptagelformSISOTF Apaliest fir. & AvLharixa!ion'SDTF PertnR Appl::alion-far 2016.doex
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 `,Naste Section
1646 Mail Service Center, Raleigh, NC 27699.1645
WV L1. (name olsite owner) hereby certify that J am the oUmer of
r [ C i ((,. ),-� 4,6
_1 _ -_ acres of land located 2 ( F H M=rl[ F. 79W )S' and
identified by (book and page of recorded deed or tax map parcel) and
that I agree to allow t l I r-v tii, ,a:X f-1IC trl VI F permit applicant) to use
said land for a septage datention or treatment facility for a period of (length
of time)begin ling ': ; ; -� - "� ' Vve dote) and that t have read the Noah Carolina
Septage Managerrent -ules ". I further understand that no septage may be stored or treated on the land
until the Division of Waste Management has issoed a perm -It •or a detention or treatment facility. The above
described p-opery is owned solely by me or jointly with _ A
(:lames of all co -owners: or state none).
i nat of Iandotvner I, r` .r;,,, ; . roI �'c Rate `�
Si a ure of landowner
Signature of landoriner
Date
�Oate
S ,'orn to and subscribed before one this day of Y 2;
{Notary Public',
I''M1y Commission expires:.,-
* 15A N.C. Admin. Code 13B Section .0800
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Rev. 01-C7-16