WQ0043983_Application_20221208

I. PRESUBMITTAL INFORMATION:
1. Contacted representative from regional office (Pre -submittal)?: ® Yes ❑ No LaWrithed
2. Contact name (For Regional Office): Robert Tankard
v1/4lQoo43c83
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 ❑ Retail (Stores, Shopping Centers Domestic: ; «100% %
❑ Apartments/Condominiums ❑ Institution Commercial:
❑ Mobile Home Park ❑ Hospital Industrial: • %
❑ School ❑ Church Other: a %
0 Restaurant ❑ Nursing Home
❑ Office ❑ Other (specify)
4. Signature authority's name: Edward Kiley per 15A NCAC 02T .0106(b)
Title: POA Vice President
5. Applicant's mailing address: PO Box 572,
City: Edenton State: NC Zip: 27932-
6. Applicant's contact information:
Phone number. [phone] Email: edkiley0303@,gmail.com
III. CONTACT/CONSULTANT INFORMATION:
1. Contact name:
Title/Affiliation:
2. Contact's information:
Phone number. ( ) _ Email:
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: Town of Hertford
2. Facility name:
3. Facility permit number.
4. WWTF permit number.
5. WWTF contact name: Harold F. Sanchez
Title/Affiliation: Public Works Director
6. WWTF contact information:
Phone number. (252) 426-3Q39 Email: [e-mail]
APPLICATION P&H 01-16 Page 3 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.
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 Engineer Name
2b.
Engineering Firm
2c.
Mailing Address
2d.
2g.
2e. i2f.
City j State
Telephone Facsimile
Zip
E-mail
NC PE Seal, Signature & Date
APPLICATION P&H 01-16 Page 5 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.: W00042527
3. Permanent Method of Wastewater Disposal: WWTP
4. Date Permanent Disposal will be available:
5. Have permits / approvals for permanent disposal been obtained?
0 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: 0 15A NCAC 02T .0114 or ❑ Representative Data
If representative data, describe: Two houses, using water bills
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 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 penalties to $25,000 er vl lation.
la. C 2
Signing Official Signature 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

RECENED/NCDENR/DWR
NCDEQ
Robert Tankard
943 Washington Square Mall
Washington NC 27889
DEC -5 2022
Water Quality
Regional Operations Section
Washington Regional Office
Robert, it appears we will need to renew the pump and haul permit for another six months. It Is hard to
believe we still do not have the new system installed. Joe Anlauf has submitted the paperwork Nathaniel
has requested for final approval. I hope this is the last request for the pump and haul permitting.
Enclosed is the check and permit request to extend us from January 1, to June 30th.
Thank you, I appreciate all the help with this process.