WQ0042527_Pump and Haul_20210514

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1. PRESUBMITTAL INFORMATION:
1. Contacted representative from regional office (Pre -submittal)?: ® Yes ❑ No
2. Contact name (For Regional Office): Robert Tankard
II. APPLICANT INFORMATION:
1. Applicant's name (Municipality, Individual, Corporation, etc): Riversound POA
2. Applicant type: ❑ Municipal ❑ State ❑ Privately -Owned Public Utility
❑ County ❑ Other: Privately Owned
3. Origin of Wastewater:
Residential Subdivision
❑ Apartments/Condominiums
❑ Mobile Home Park
0 School
❑ Restaurant
0 Office
❑ Retail (Stores, Shopping Centers)
❑ Institution
❑ Hospital
❑ Church
0 Nursing Home
❑ Other (specify)
4. Signature authority's name: George Hill per 15A NCAC 02T .0106(b)
Title: POA President
5. Applicant's mailing address: PO Box 572
City: Edenton State: NC Zip: 27932-
6. Applicant's contact information:
Phone number: [phone]
III. CONTACT/CONSULTANT INFORMATION:
1. Contact name:
Title/Affiliation:
2. Contact's information:
Phone number: (_) = Email:
IV. RECEIVING FACILITY INFORMATION:
Email: [e-mail]
Domestic:
Commercial:
Industrial:
Other:
100
If more than 1 facility has agreed to accept the wastewater, please list all the owners, facility names, and permit
numbers as a separate attachment)
1. Owner: Town of Hertford
2. Facility name:
3. Facility permit number:
4. WWTF permit number:
5. WWTF contact name: Harold F. Sanchez
Title/Affiliation: Publics works Director
6. WWTF contact information:
Phone number: [phone]
Email: [e-mail]
APPLICATION P&H 01-16 Page 3 of 5

V. PROJECT INFORMATION:
1. Duration of Pump and Haul Request (Six Months Typical): 6 Months
2. Has a prior permit been issued?
New ❑ Prior Pump & Haul Permit
Permit No.:
3. Permanent Method of Wastewater Disposal: WWTP
4. Date Permanent Disposal will be available:
5. Have permits / approvals for permanent disposal been obtained?
❑ Yes ❑ No Permit Number:
6. Is there a Pretreatment Program in effect? ❑ Yes ® No
7. Describe any pretreatment prior to pumping and hauling:
8. Volume of Wastewater Generated: 300 Gallons per Day
9. Explain how the wastewater flow was determined: ❑ 15A NCAC 02T .0114 or ❑ Representative Data
If representative data, describe: Two houses, monthly water bill
10. Describe Tank / Container wastewater will be pumped from (attach description if necessary):
Equalizing Tank
11. Is Tank / Container in place or will it be installed (attach description if necessary):
In Place
12. What type of high water alarm does the container have:
❑ Audible and Visual ❑ Telemetry (Auto Dialer / SCADA)
VI. CERTIFICATION:
1.
Applicant's Certification: (Signature of Signing Official and Project Name)
I, Edward Kiley , attest that this application for Riversound POA Pump and Haul
_ has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts
of this application are not completed and that if all required supporting documentation and attachments are not included, this
application package is subject to being returned as incomplete. I understand that issuance of a permit will require pump and
haul facilities or activities to be inspected at least daily by me or a designated representative. Note: In accordance with North
Carolina General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement, representation,
or certification in any application shall be guilty of a Class 2 misdemeanor, which may include a fine not to exceed $10,000 as
well as civil pe [ties up to $2 ,000 per violation.
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Signing Official Signa ure Date
ENGINEERING DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL.
ACTIVITIES SHALL BE INSPECTED AT LEAST DAILY BY THE PERMITTEE OR IT'S REPRESENTATIVE PER 15A NCAC 02T .0204(d).
APPLICATION P&H 01-16
Page 4 of 5

EARNELL BROWN
MAYOR
PAMELA W. HURDLE
TOWN MANAGER
OLGA SIMPSON
CLERK
BENJAMIN M. GALLOP
TOWN ATTORNEY
May 11, 2021
Ed Kiley
3932 Valley Side Ct
Cary, NC 27519
Dear Mr. Kiley;
COMMISSIONERS:
ASHLEY HODGES
MAYOR PRO TEM
QUENTIN JACKSON
FRANK NORMAN
JERRY MIMLITSCH
The Town of Hertford agrees to accept wastewater pumped from your facility and
transported in an appropriate liquid waste hauling vehicle and brought to our facility for
treatment under the following conditions:
• The designated hauler(s) will have to have an authorization to discharge form from the
NC Department of Environmental Quality department filled out and on file at the
facility.
• Wastewater will only be taken between the hours of 09:00 A.M. and 3:30 P.M.
• Contact with plant staff shall be made prior to dumping.
• Dumping will only be allowed at designated sites with Town staff present.
• Since there is no way to measure the amount of liquid in the truck, it will always be
assumed to be full.
• Waste shall be hauled by an individual/company licensed in the State of North
Carolina for the conveyance of such wastes.
• Any damage to Town equipment by hauler shall be replaced or repaired by the sender
of said waste and or hauler.
• Spills shall be cleaned up by hauler at the time of the spill, and Town staff notified of
said spillage.
• Payments will be monthly and due by the 20th of each month.
• Period of this service: May 12, 2021 to November 12, 2021
Town of Hertford • P.O. Box 32. 114 West Grubb • Hertford, North Carolina 27944
Phone [phone] • Fax [phone] • [e-mail]

EARNELL BROWN
MAYOR
PAMELA W. HURDLE
TOWN MANAGER
OLGA SIMPSON
CLERK
BENJAMIN M. GALLOP
TOWN ATTORNEY
COMMISSIONERS:
ASHLEY HODGES
MAYOR PRO TEM
QUENTIN JACKSON
FRANK NORMAN
JERRY MIMLITSCH
The Town will charge $0.10 per gallon. The dump site will be coordinated with your carrier
but will likely be at the treatment facility headworks. The Town reserves the right to
terminate this agreement at any time if these conditions are not met. This will be done with
appropriate notice.
If you have any questions or need any further information, please fee free t contact me at
[phone] or [e-mail].
Sincerely,
Pamela Hurdle
Town Manager
Town of Hertford • P.O. Box 32. 114 West Grubb • Hertford, North Carolina 27944
Phone [phone] • Fax [phone] • [e-mail]

Edward Kiley
Riversound POA
P.O. Box 572
Edenton NC 27932
Robert, we have arranged to have Lassiter Septic Tank Service (127 Askewville Bryant St. 252-794-5444)
haul our wastewater to the Town of Hertford for a period of six months. We plan of hauling up to 10,000
gallons per month.
Thank you,
Ed Kiley