WQ0022669_Application (FTSE)_20030519

•
FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
1. Owner:
1 a. Town of Elizabethtown
Application Number:
(to be completed by DWQ) GCJ4)O4 (p 6* 9
Full Legal Name (company, municipality, HOA, utility, etc.)
z 1 b. David M. Smitherman, Town Manager
O Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for authorized s igni f l aA!)O3
F' - 1c. The legal entity who will own this system is:
Ilk ❑ Individual 0 Federal_El Municipality 0 State/County 0 Private Partnership (] Corporatidn jj tO(h9r (specify):
c ld. PO Box 716 le. Elizabethtown
O Street Address City
LL
Z lf. NC
State
O 1 h. 910-862-2066
1 i. 910-862-7117
1 g. 28337
Zip Code
1 j. [e-mail]
Telephone Facsimile
() 2. Project (Facility) Information:
J
a
a
Q 3a. Robert P. Armstrong, Jr.
Name and Affiliation of Someone Who Can Answer Questions About this Application
E-mail
2b. Bladen County
2a. 3ro. Ave. Sanitary Sewer Extension
Brief Project Name (permit will refer to this name)
3. Contact Person:
County Where Project is Located
3b. 910-863-3205 3c. [e-mail]
Phone Number E-mail
. Project is ® New 0 Modification (of an existing permit) If Modification, Permit No.:
2. Owner is ® Public (skip to Item B(3)) ❑ Private (go to Item 2(a))
2a. If private, applicant will be:
❑ Retaining Ownership (i.e. store, church, single office, etc.) or
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3))
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
2b. If sold, facilities owned by a (must choose one)
❑ Public Utility (Instruction III)
❑ Homeowner Assoc./Developer (Instruction IV)
O3 Town of Elizabethtown
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
• 4a. Elizabethtown WWTP
Name of WWTF
O 5a. Town of Elizabethtown
L Owner of Downstream Sewer
. The origin of this wastewater is (check all that apply):
4b. NC002i'9bl
WWTF Permit No.
5b. 8"
Receiving Sewer Size
5c.
Permit Number of Downstream Sewer (if known)
H
r[
W
0
® Residential Subdivision
❑ Apartments/Condominiums
❑ Mobile Home Park
❑ School
0 Restaurant
0 Office
❑ Car Wash
O Institution
❑ Hospital
❑ Church
0 Nursing Home
❑ Other (specify):
100 % Domestic/Commercial
Industrial
Other (specify):
. Volume of wastewater to be permitted in this project: 3600 gallons per day
. If the permitted flow is zero, indicate why:
❑ Interceptor Line - Flow will be permitted is subsequent permits that connect to this line
❑ Flow has already been allocated in Permit No.
O Rehabilitation or replacement of existing sewer with no new flow expected