WQ0015487_Permit Renewal_20060923

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State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
INSTRUCTIONS FOR FORM: W WR 09-06
(RENEWAL WITHOUT MODIFICATION OF WASTEWATER NON -DISCHARGE SYSTEMS)
Ior more information or for an electronic version of this form, visit the Land Application Unit (LA U) web site at:
hitn Ilh2o enr state nc us/lau/ntain hnn!
TOis form is for renewal without modification for all wastewater non -discharge systems. Wastewater non -discharge
systems include.: High Rate Infiltration Systems, Infiltration/Evaporation Lagoons, Reclaimed Water Utilixmam
4,stems; Wastewater Recycle Systems; Single Family Surface Irrigation Systems; and Surface Irrigation Smauns.
This application may not be used for renewal ofLand.4pylication of -Residuals of-ResidualsPermits.
A. Application Form (All Application Packages):
✓ Submit one (1) original and two (2) copies of the completed and appropriately executed application form.
Any changes made to this form will result in the application package being returned.
✓ If the Applicant is a corporation or company, it must be registered for business with the NC Secretary of
SMW(htto'//www.secremry.state.ne.us/Colporations/CSearch.as I..
✓ If the Applicant is a partnership, sole proprietorship, trade name, or d/b/a enclose a copy of the certificate
filed with the register of deeds in the county of business.
✓ The application must be signed appropriately in accordance with 15A. NCAC 2T .0106(b). An alternate
person may be designated as the signing official, provided that a delegation letter is provided from a person
who meets the referenced criteria. You may download an example delegation letter from the LAU web site.
✓ Submit three (3) copies of the most recently issued existing permit.
B. Additional Forms (Single Family Residence Surface Irrigation Systems Only):
✓ Submit one (1) original and two (2) copies of a completed and properly executed FORM: SIR O&M 09-
06. This Form may be downloaded at: .htta�/ih2o.enr.statc,nc.us/lau/amlications,html#SingI'
C. Site Map
✓ Submit three (3) copies of an updated site map if required as part of the original submittal in accordance -
with 15A NCAC 2T .0105(d).
RECENLO I DENR I DVVQ
AQUIFFR'PRO 'IFMION SFCTION
I. GENERAL INFORMATION: jI. P 2 7 HOG
1. Pennittee's name. (Owner of the facility): Carl Powell Jr.
2. Complete mailing address ofPemnttee: PO Box 65
City: Waynesville State: NC Zip: 28786
Telephone number: [phone]_ Facsimile number: [phone]
Email Address:
3. Facility name (name of the subdivision, shopping center, etc.): Powell Industries Chipper Mill, ribs
Suncrest Land & Timber
4. Complete address of the physical location of the facility (if different from above): 4595 Jonathan Creek Rd
City: Wavnesville State: NC Zip: 28785
5. County where project is located: Haywood
6. Name and affiliation ofcontactperson who can answer questions about project: .Mitchell Powell Officer
(,SA kb Email Address:
FORM: WWR 09-06 Page 1

11. PERMIT INFORMATION:
1. Existing permit number _W00015487 and the issuance data June 15, 1998_
2. Existing permit type:
❑ High -Rate Infiltration ❑ Evaporation Lagoons ❑ Reclaimed Water Utilization
❑ Single Family Surface Irrigation. ❑ Surface Irrigation ® Wastewater Recycle
3. Has the treatment and disposal system been constructed? ® Yes ❑ No
4. If the system has not been constructed, would you like to rescind your permit (i.e. the permitted facilities
will not be needed)? ❑ Yes ❑ No
5. Has the wastewater system been connected to a municipal or community sewer system? ❑ Yes ® No
attest that this application for Powell Industries: dba Suncrest Land & Timber
(facility name)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that any discharge
of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against
the Division of Water Quality should a condition of this permit be violated. I also understand that if all required
parts of this application package are not completed and that if all required supporting information and attachments
are not included, this application package will be returned to me as incomplete. I further certify that the applicant or
say affiliate has not been convicted of an environmental crime, has not abandoned a wastewater facility without
proper closure, does not have an outstanding civil penalty whereall appeals have been exhausted or abandoned, are
compliant with any active compliance schedule, and do not have any overdue annual fees under Rule 2T ,0105,
Nate: 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 package shall be guilty of a Class 2 misdemeanor,.
which may mclu nenot to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature: Date: 3 (�
THE COMPLETED RENEWAL APPLICATION SHALL BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
By U.S. Postal Service:
1636 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1636.
TELEPHONE NUMBER: [phone]
By Courier/Special Delivery: .
2728 CAPITAL. BOULEVARD
RALEIGH, NORTH CAROLINA 27604
FAX NUMBER: [phone]
RECEIVED / DENR / DWQ
AQUIFFR-PROTFffm RFCTION
SEP 2, 7 2006
FORM: WWR09-06 - Paget