WQ0043404_Pump & Haul_20220429

vk! go 1-3 404
I. PRESUBMITTAL INFORMATION:
1. Contacted representative from regional office (Pre -submittal)?: x Yes 0 No
2. Contact name (For Regional Office): Robert Bullock
II. APPLICANT INFORMATION:
1. Applicant's name (Municipality, Individual, Corporation, etc): Gates County Board of Education
2. Applicant type: 0 0 Municipal 0 0 State 0 ❑ Privately -Owned Public Utility
❑ ❑ ❑ County x Other: School System
3. Origin of Wastewater:
❑ ❑ 0 Residential Subdivision 0 0 Retail (Stores, Shopping Centers) Domestic:
❑ ❑ Apartments/Condominiums ❑ ❑ Institution Commercial:
❑ ❑ Mobile Home Park ❑ ❑ Hospital Industrial:
❑x School ❑ ❑ Church Other:
❑ ❑ Restaurant ❑ ❑ Nursing Home
0 Office 0 0 Other (specify)
4. Signature authority's name: Dr. Barry Williams per 15A NCAC Q2T .0106(b)
Title: School Superintendent
5. Applicant's mailing address: PO Box 125
City: Gatesville State: NC Zip: 27938
&_Applicant's contact information:
Phone number: [phone] Email: [e-mail]
III. CONTACT/CONSULTANT INFORMATION:
1. Contact name: John Greene
Title/Affiliation: Maintenance Director
2. Contact's information:
Phone number: [phone] Email:[e-mail]
IV. RECEIVING FACILITY INFORMATION:
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: Ahoskie & Windsor
L.Facility name:
3. Facility permit number:
4. WWTF permit number: NC0088561 & NC0026751
5. WWTF contact name:
Title/Affiliation:
6. WWTF contact information:
Phone number: ( ) = Email:
APPLICATION P&H 01-16 Page 3 of 5

V. PROJECT INFORMATION:
1. Duration of Pump and Haul Request (Six Months Typical): Six Months
2. Has a prior permit been issued? No ❑ ❑ New ❑ ❑ Prior Pump & Haul Permit
Permit No.:
3. Permanent Method of Wastewater Disposal: Re -Circulating Sand Filter
4. Date Permanent Disposal will be available: July 1,2022
5. Have permits / approvals for permanent disposal been obtained?
x Yes ❑ ❑ No Permit Number: N00033782
6. Is there a Pretreatment Program in effect? 0 ❑ ❑ Yes X No
7. Describe any pretreatment prior to pumping and hauling:NA
8. Volume of Wastewater Generated:Less Than 5,0000 gallons per day Gallons per Day
9. Explain how the wastewater flow was determined: x 15A NCAC 02T .0114 or 0 Representative Data
If representative data, describe:
10. Describe Tank / Container wastewater will be pumped from (attach description if necessary):6,000 gallon &
1,000 gallon concrete septice tanks.
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:
x Audible and Visual 0 0 Telemetry (Auto Dialer / SCADA)
VI. CERTIFICATION:
1.
Applicant's Certification: (Signature of Signing Official and Project Name)
I, 1! ` rrt.? U ; til; r.-6,.5' , attest that this application forL,/odwl. v,1- Pint 1-14J S as been reviewed by me and is
accurate andlcomplete 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 143-21S.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 penalties up to $25,000 per violation.
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176 Zz—
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SfQnlnQ Official signature o.r.
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

•
THE ENGINEER'S CERTFICATION IS REQUIRED FOR ACTIVITIES THAT RESULT IN THE PRACTICE OF ENGINEERING PER G.S. 89C-3.
ENGINEERING DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL IF CERTIFICATION BY AND ENGINEER IS REQUIRED,
THIS PAGE IS NOT NECESSARY.
2. Professional Engineer's Certification: (Signature of Design Engineer and Project Name)
I, ,attest that this application for has been reviewed by me and is
accurate, complete and consistent with the information In the engineering plans, calculations, and all other supporting
documentation to the best of my knowledge. I further attest that to the best of my knowledge the proposed design has
been prepared In accordance with all the applicable regulations. Although other professionals may have developed certain
portions of this submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this
material and have judged it to be consistent with the proposed design. Note: In accordance with NC 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 penalties
up to $25,000 per violation.
2a.
Professional Ertglrwr Name
2b.
Engineering Firm
2c.
Mailing Address
2d.
atv
2e.
State
2f.
Zip
2g.
Telephone
2h. 2i.
Facsimile E-mail
NC PE Seal, Signature & Date
APPLICATION P&H 01-16 Page 5 of 5

JOHN O. GREENE LYNNE J. ROUNTREE
MAINTENANCE DIRECTOR ADMINISTRATIVE ASSISTANT
PUBLIC SCHOOLS OF GATES COUNTY
SCHOOL FACILITIES MAINTENANCE
POST OFFICE BOX 125
117 SCHOOL MAINTENANCE ROAD
GATESVILLE, NC 27938
PHONE [phone]
FAX [phone]
April 26, 2022
Robert Bullock
Washington Regional Office
Water Quality Operations
943 Washington Square Mall
Washington, NC 27889
Dear Mr. Bullock,
RECEIVED/NCDENR/DWR
APR 2"g 2022
Water Quality
Regional Operations Section
Washington Regional Office
The Greenhouse over the Gatesville Elementary Wastewater Site collapsed as a storm passed over Thurs.,
April 7, 2022. At the time the area was under a Tornado Warning. The wastewater tanks that pump to the
plant are being pumped by Lassiters Septic Service while the plant is inoperable. The steel structure was
removed from the berm by Wed., April 13 to assess damages. Approximately half of the 3/4" steel standpipes
for the spray heads were broken off in the ground where they meet the 3" PVC Tee. We are currently working
with insurance to try to get coverage for the necessary repairs.
Please see the enclosed application for the pump and haul permits.
Sincerely,
Jbhn 0 Greene III
Gates County Schools
Maintenance Director

I. PRESUBMITTAL INFORMATION:
1. Contacted representative from regional office (Pre -submittal)?: x Yes ❑ No
2. Contact name (For Regional Office): Robert Bullock
II. APPLICANT INFORMATION:
1. Applicant's name (Municipality, Individual, Corporation, etc): Gates County Board of Education
2. Applicant type: 0 0 Municipal 0 0 State ❑ ❑ Privately -Owned Public Utility
❑ ❑ ❑ County x Other: School System
3. Origin of Wastewater:
❑ ❑ ❑ Residential Subdivision 0 0 Retail (Stores, Shopping Centers) Domestic:
❑ ❑ Apartments/Condominiums ❑ ❑ Institution Commercial: %
❑ ❑ Mobile Home Park 0 0 Hospital Industrial:
❑x School ❑ ❑ Church Other: %
❑ ❑ Restaurant ❑ ❑ Nursing Home
❑ Office 0 0 Other (specify)
4 Signature authority's name: Dr. Barry Williams per 15A NCAC 02T .01,06(b)
Title: School Superintendent
5. Applicant's mailing address: PO Box 125
City: Gatesville State: NC Zip: 27938
6. Applicant's contact information:
Phone number: [phone] Email: [e-mail]
HI. CONTACT/CONSULTANT INFORMATION:
1. Contact name: John Greene
Title/Affiliation: Maintenance Director
2. Contact's information:
Phone number. [phone] Email:[e-mail]
IV. RECEIVING FACILITY INFORMATION:
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: Ahoskie & Windsor
,Facility name:
Facility permit number:
4. WWTF permit number: NC0088561 & N00026751
5. WWTF contact name:
Title/Affiliation:
,_WWTF contact information:
Phone number: ( ) = Email:
APPLICATION P&H 01-16 Page 3 of 5

V. PROJECT INFORMATION:
1. Duration of Pump and Haul Request (Six Months Typical): Six Months
2. Has a prior permit been Issued? No 0 0 New ❑ ❑ Prior Pump & Haul Permit
Permit No.:
3. Permanent Method of Wastewater Disposal: Re -Circulating Sand Filter
4. Date Permanent Disposal will be available: July 1,2022
5. Have permits / approvals for permanent disposal been obtained? -
x Yes ❑ ❑ No Permit Number: NC0033782
6. Is there a Pretreatment Program in effect? ❑ ❑ ❑ Yes X No
7. Describe any pretreatment prior to pumping and hauling:NA
8. Volume of Wastewater Generated:Less Than 5,0000 gallons per day Gallons per Day
9. Explain how the wastewater flow was determined: x 25A NCAC 02T .0114 or 0 Representative Data
If representative data, describe:
10. Describe Tank / Container wastewater will be pumped from (attach description if necessary):6,000 gallon &
1,000 gallon concrete septice tanks.
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:
x Audible and Visual
VI. CERTIFICATION:
0 0 Telemetry (Auto Dialer / SCADA)
1. Applicant's Certification: (Signature of Signing Official and Protect Name)
I, Dr,43 r 1,1 0161S , attest that this application fort fo4,Pu, 4 ilexA as been reviewed by me and is
accurate andl 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 induded, 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 143-215.68, 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 penalties up to $25,000 per violation.
la. �1� .�.. 1
t /zJ2zz-
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

THE ENGINEER'S CERTFICATION IS REQUIRED FOR ACTIVITIES THAT RESULT IN THE PRACTICE OF ENGINEERING PER GS. 89C-3.
ENGINEERING DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL. IF CERTIFICATION BY AND ENGINEER IS REQUIRED,
THIS PAGE IS NOT NECESSARY.
2. Professional Engineer's Certification: (Signature of Design Engineer and Protect Name)
2a.
2b.
2c.
I, ,attest that this application for has been reviewed by me and Is
accurate, complete and consistent with the information in the engineering plans, calculations, and all other supporting
documentation to the best of my knowledge. I further attest that to the best of my knowledge the proposed design has
been prepared In accordance with all the applicable regulations. Although other professionals may have developed certain
portions of this submittal package, Inclusion of these materials under my signature and seal signifies that I have reviewed this
material and have judged it to be consistent with the proposed design. Note: In accordance with NC 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 penalties
up to $25,000 per violation.
Professional Engineer Name
Engineering Finn
Mailing Address
1
2d. 12e. 2f.
city sftte
Zip
T2h.
Telephone Faahn<le
NC PE Seal, Signature & Date
APPLICATION P&H O 1-16 Page .5 of 5