WQ0002364_Request Form_20210521

State of North Carolina
Dw R Department of Environmental Quality
Division of Water Resources
WATER QUALITY REGIONAL OPERATIONS SECTION
Division of Water Resources NON-DISCHARGE PERMIT RESCISSION REQUEST FORM
May 21,2021
To: WaRO-WQROS: David May/Robert Tankard
From: Nathaniel D. Thornburg, Water Quality Permitting Section-Non-Discharge Branch
Permit Number: WQ0002364 Permit Type: Single-Family Residence Wastewater Irrigation
Permittee: Michael D. and Martha F.Hardison Date Rescission Requested: May 21,2021
Facility Name: 650 Sim Dawson Rd. SFR Date of Last Inspection: February 10, 2014
Comments: See attached rescission request.
Please complete this form and return to the Central Office within 30 days of receipt.
Jg' Site visit performed. gl Permit rescission approved. ❑ Permit rescission denied.
Comments:
WQROS Reviewer: a�� Date: 11 /t 3/Z-
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FORM: WQROSNDPRR 08-17 Page 1 of 1