640021_Application_20210925 (2)

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Animal Feeding Operations Permit Application Form
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
State General Permit - Existing Animal Waste Operations
1. GENERAL INFORMATION:
1.1 Facility name: 1jtt�'Li-i'..11\ex-s
1.2 Print Land Owner's name: �S frv.` L LC.
1.3 Mailing address: (069 I
City, State: h0\`L� ) a Zip: d. 1 O�
Telephone number (include area code): (:2.0) 6'4 - 3,.Lt- �oRS
1.4 Physical address:���aLL2 J 5- M umi FGu('1N\ 1F`•
`
City, State: .��l�\T ems, NC.. L'7 CI, 1 Zip: )--1 S9
Telephone number (include area code): ( ) ��� - 31(/dv
1.5 County where facility is located: N (s\(-1 1 I -
1.6 Facility location (directions from nearest major highway, using SR numbers for state roads): C; t— 151 1 Frim � (D1
1.7 Farm Manager's name (if different from Land Owner): 61f e k i510Nu_ H`W' 33. ( r - \S
�Ux r l 11414-SOt• Seed 1.8 Lessee's / Integrator's name (if applicable; circle which type is listed): /'�' �1 „S `c4-0
1.9 Facility's original start-up date: Date(s) of facility expansion(s) (if applicable):
2. OPERATION INFORMAThTION:
2.1 Facility number: (44 ' V
2.2 Operation Description:
Please enter the Design Capacity of the system. The "No. of Animals" should be the maximum number for which the waste
management structures were designed.
Type of Swine No. of Animals Type of Poultry No. of Animals Type of Cattle No. of Animals
can to Feeder ❑ Layer ❑ Beef Brood Cow
❑ Feeder to Finish ❑ Non -Layer ❑ Beef Feeder
l farrow to Wean (# sow) ❑ Turkey ❑ Beef Stocker Calf
❑ Farrow to Feeder (# sow) ❑ Turkey Poults ❑ Dairy Calf
❑ Farrow to Finish (# sow) ❑ Dairy Heifer
❑ Wean to Finish (# sow) El Dry Cow
[]-Gilts C) ❑ Milk Cow
❑ Boar/Stud
❑ Other Type of Livestock on the farm: No. of Animals:
FORM: AWO-STATE-G-E 10/31/18 Page 1 of 5

2.3 Acreage cleared and available for application (excluding all required buffers and areas not covered by the application
system): 3Required Acreage (as listed in the CAWMP): 8' .o c,usre!`vY
24,'(01
2.4 Number of lagoons: Total Capacity (cubic reei):•• Required Capacity (cubic feet): Z gni L91/"1
Number of Storage Ponds: NA Total Capacity (cubic feet): Ha- Required Capacity (cubic feet): N P
2.5 Are subsurface drains present within 100' of any of the application fields?
2.6 Are subsurface drains present in the vicinity or under the waste management system?
2.7 Does this facility meet all applicable siting requirements?
3. REQUIRED ITEMS CHECKLIST:
YES or
YES or
circle one)
(circle one)
or NO (circle one)
Please indicate that you have included the following required items by signing your initials in the space provided next to each
item.
3.1 One completed and signed original and two copies of the application for State General Permit -
Animal Waste Operations;
3.2 Three copies of a general location map indicating the location of the animal waste facilities and
field locations where animal waste is land applied and a county road map with the location of the
facility indicated;
3.3 Three copies of the entire Certified Animal Waste Management Plan (CAWMP). If the facility
does not have a CAWMP, it must be completed prior to submittal of a permit application for
animal waste operations.
Applicants Initials
RS if
Rs$
fU
The CAWMP must include the following components. Some of these components may not have been required at the time
the facility was certified but should be added to the CAWMP for permitting purposes:
3.3.1 The Waste Utilization Plan (WUP) must include the amount of Plant Available Nitrogen (PAN) produced and
utilized by the facility
3.3.2 The method by which waste is applied to the disposal fields (e.g. irrigation, injection, etc.)
3.3.3 A map of every field used for land application
3.3.4 The soil series present on every land application field
3.3.5 The crops grown on every land application field
3.3.6 The Realistic Yield Expectation (RYE) for every crop shown in the WUP
3.3.7 The PAN applied to every land application field
3.3.8 The waste application windows for every crop utilized in the WUP
3.3.9 The required NRCS Standard specifications
3.3.10 A site schematic
3.3.11 Emergency Action Plan
3.3.12 Insect Control Checklist with chosen best management practices noted
3.3.13 Odor Control Checklist with chosen best management practices noted
3.3.14 Mortality Control Checklist with the selected method noted
3.3.15 Lagoon/storage pond capacity documentation (design, calculations, etc.); please be sure to include any site
evaluations, wetland determinations, or hazard classifications that may be applicable to your facility
3.3.16 Operation and Maintenance Plan
If your CAWMP includes any components not shown on this list, please include the additional components with your
submittal. (Composting, waste transfers, etc.)
FORM: AWO-STATE-G-E 10/31/18 Page 2 of 5

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4. APPI CANT'S CERTIFICATION:
I, "+.4e 4' ii;&A,,,r/e-e ri -t ur Do 5 Gc.-1<.A %+i (-1-((Land Owner's name listed in question 1.2), attest that
this application for UJs (Facility name listed in question 1.1)
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 information and attachments are not included, this application package
will be returned to rjle,as incomplete.
Signature
Date
VOV)-(
5. MANAGER'S CERTIFICATION: (complete only if different from the Land Owner)
I, (Manager's name listed in question 1.6), attest that this
application for (Facility name listed in question 1.1)
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 information and attachments are not included, this application package
will be returned as incomplete.
Signature Date
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING INFORMATION, MATERIALS, AND ANY
DESCRIPTION OF THE FACILITY OR MODIFICATIONS SHOULD BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DIVISION OF WATER RESOURCES
ANIMAL FEEDING OPERATIONS & GROUNDWATER PROTECTION SECTION
ANIMAL FEEDING OPERATIONS PROGRAM
1636 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1636
TELEPHONE NUMBER: [phone]
FAX NUMBER: [phone]
FORM: AWO-STATE-G-E 10/31/18 Page 3 of 5