WQ0022413_Sewer Extension Permit Status Update_20200122

RECEIVED
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NCDEQ/DWI
Request for Engineering Certification r: December 17,2019
Sewer Extension Permit Status Update
Please complete the applicable portion of this form for each permit and return this form and supporting documents by January 20,
2020 to the attention of Nyle Hothem at the Division's PERCS Unit by the delivery method below:
NCDEQ/DWR
WQPS—PERCS UNIT
By U.S.Postal Service: By Courier/Special Delivery: By Email:
1617 Mail Service Center 512 N.Salisbury St.Suite 925 Nyle Hothem
Raleigh, NC 27699-1617 Raleigh,NC 27604 [e-mail]
Permit No.:WQ0022413 Permittee: Paul Smith
Project Name:8204 Craighead Road
Project Status (Check appropriate box to indicate Permittee's response and complete&sign below)
SEWER NOT CONSTRUCTED
_0 The Permittee certifies that tbig permitted project has not been constructed but shall be constructed in the future in conformity
with the approved Permit,project plans,specifications,and supporting documents.The Permittee understands that the
appropriate certification documents will need to be forwarded to the Division prior to operation. Subject permit shall be
maintained in Active status. NOTE:If sewer will never be built,please complete Permit Rescission Request section below.
SEW R HAS BEEN CONSTRUCTED [Check one]
Permittee's Certification:The Permitted project has been constructed and the required Engineer's Certification and supporting
documents are not available. However,the undersigned agent for the Permittee hereby states that to the best of[his/her]
knowledge,this project has been constructed pursuant to the applicable standards&requirements of the Permit issued for the
above named project and the Permittee is presently operating and maintaining the wastewater collection system in accordance
with the conditions of the Permit. The permitted system was placed into service in T p O„j 1(insert month& year].
❑ Engineer's Certification: The Permitted project has been constructed and the required Engineer's Certification and supporting
documents are being submitted to the Division with this form.
OWNERSHIP/NAME CHANGE
❑ The Permittee requests information to apply for ownership or name change. Please provide email and phone number below for
follow-up.
A . � ifQv2i./4 r
Name&Tide(print): d.L
Signature: _____Date: . j 9-" a
Comments: •
Permit Rescission Request
The Permittee requests that the subject permit be rescinded and certifies that the permitted sewer system has not been and shall
not be constructed nor made operational.We understand that,in the future,should we wish to operate a non-discharge sewer
system,we shall apply for and receive a new Wastewater Collection System Permit.
Name&Title(Print):
Signature: Date:--___-
Comments:
Contact Information Updates for Current Owner
Updated Contact Person&Title(Print): pA./(cm 4 35-t_��c4_ p/ • G orh7 of f v-e_r