WQ0003626_Final Permit_20050210

aOF WATFRQ Michael F. Easley, Govemor
William G. Ross Jr., secretary
North Carolina Department or Environmenland Natural Resources
(] Alan W. Klimek, P.E. Director
Division of Water Quality
February 10, 2005
A.F. GEORGE— VICE PRESIDENT
CAMPBELL SOUP SUPPLY COMPANY, LLC
2120 NC Hwy 71 NORTH
MAXTON, NORTH CAROLINA 28364
Subject: Permit No. WQ0003626
Campbell Soup Company — Maxton
Plant & Silgan Can Company
Wastewater Treatment and Surface
Irrigation
Robeson County
Dear Mr. George:
In accordance with your permit modification request received January 20, 2005, and subsequent
additional information received January 24, 2005, we are forwarding herewith Permit No. WQ0003626,
dated February 10, 2005, to Campbell Soup Supply Company, LLC for the construction and continued
operation of the subject wastewater treatment and surface irrigation facilities.
This permit shall be effective from the date of issuance until May 31, 2009, shall void Permit No.
WQ0003626 issued June 11, 2004, and shall be subject to the conditions and limitations as specified
therein. Please pay particular attention to the monitoring requirements in this permit. Failure to establish
an adequate system for collecting and maintaining the required operational information will result in
future compliance problems.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the
right to request an adjudicatory hearing upon written request within thirty (30) days following receipt of
this permit. This request must be in the form of a written petition, conforming to Chapter 150E of the
North Carolina General Statutes, and filed with the Office of Administrative Hearings, 6714 Mail Service
Center, Raleigh, NC 27699-6714. Unless such demands are made this permit shall be final and binding.
One set of approved plans and specifications is being forwarded to you. If you need additional
information concerning this matter, please contact Nathaniel Thornburg at [phone].
Alan W. Klimek, P
cc: Robeson County Health Department
Fayetteville Regional Office, Aquifer Protection Section
Ray S. Taylor, PE-- O'Brien & Gere Engineers
APS Central Files
`1 AU Files
No 1hCarolins
Naturally
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1036 Phone [phone] Customer Service
Internet: h2o.enr.state.nc.us 2728 Capital Boulevard Raleigh, NC 27604 FAX [phone]M 1-877-623-6748
An Equal OpportunilylAffinnative Action Employer— 50%. Recycled/10% Post Consumer Paper

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH
SURFACE IRRIGATION SYSTEM PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Campbell Soup Supply Company, LLC
Robeson County
FOR THE
construction and operation of a surface irrigation treatment and disposal facility consisting of
approximately 54 acres divided into eleven (1I) separate irrigation zones and all associated piping,
valves, controls and appurtenances, and the
continued operation of a 4.0 million gallon per day (MGD) surface irrigation treatment and disposal
facility consisting of a Parshall flume with a flow recorder/totalizer, a mechanical bar screen, a lime slurry
system for pH and odor control, six (6) 800 gallon per minute (GPM) influent pumps, one (1) 4 foot 1,064
GPM rotary screen, three (3) 6 foot 1,700 GPM rotary screens, a 217,000 gallon dissolved air flotation
unit with a 1,471 GPM recycle pump, an air -saturation tank with a 30 cubic feet per minute (CFM)
compressor, a 200 GPM grit pump, a 20 GPM scum/grease rotary positive displacement pump, a 200
GPM sludge cyclone and 50 CFD classifier, a 23,000 gallon. clearwell with six (6) 800 GPM pumps, a
spray irrigation pump station with six (6) 800 GPM pumps and a high-water alarm, six (6) programmable -
controller spray irrigation center -pivot systems and one (1) solid -set irrigation system, approximately 334
acres of irrigation fields, an emergency standby 8.6-acre land application row and furrow system for use
during power outages or during inclement weather only as necessary to prevent a discharge from the
remaining irrigation fields, and all associated piping, valves, controls, monitoring and sampling
equipment, and appurtenances to serve the Campbell Soup's Maxton Plant and Silgan Can Company,
with no discharge of wastes to the surface waters, pursuant to the application received January 20, 2005,
and subsequent additional information received by the Division, and in conformity with the project plan,
specifications, and other supporting data subsequently filed and approved by the Department of
Environment and Natural Resources and considered a part of this permit.
This permit shall be effective from the date of issuance until May 31, 2009, shall void Permit No.
WQ0003626 issued June 11, 2004, and shall be subject to the following specified conditions and
limitations:

1. PERFORMANCE STANDARDS
Upon completion of construction and prior to operation of this permitted facility, a certification must
be received from a professional engineer certifying that the permitted facility has been installed in
accordance with this permit, the approved plans and specifications, and other supporting materials. If
this project is to be completed in phases and partially certified, you shall retain the responsibility_ to
track further construction approved under the sarne permit, and shall provide a final_ certificate of
completion once the entire project has been completed. Mail the Certification to the Land
Application Unit, Division of Water Quality, 1636 Mail Service Center, Raleigh, NC 27699-1636.
2. The Fayetteville Regional Office, telephone number [phone], shall be notified at least forty-
eight (48) hours in advance of operation of the installed facilities so that an in -place inspection can be
made. Such notification to the regional supervisor shall be made during the normal office hours from
8.00 a.m. until 5:00 p.m. on Monday through Friday, excluding State Holidays.
3. The surface irrigation facilities shall be effectively maintained and operated at all times so that there
is no discharge to the surface waters, nor any contamination of ground waters, which will render them
unsatisfactory for normal use. In the event that the facilities fail to perform satisfactorily, including
the creation of nuisance conditions or failure of the irrigation area to adequately assimilate the
wastewater, the Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality, such as the construction of additional or replacement
wastewater treatment and disposal facilities.
4. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface
or groundwaters resulting from the operation of this facility.
S. The residuals generated from these treatment facilities must be disposed in accordance with General
Statute 143-215.1 and in a manner approved by the Division.
6. Diversion or bypassing of the untreated wastewater from the treatment facilities is prohibited.
7_ The following buffers shall be maintained:
a) 400 feet between wetted area and any residence or places of public assembly under separate
ownership,
b) 150 feet between wetted area and property lines,
c) 100 feet between wetted area and wells,
d) 100 feet between wetted area and drainage ways or surface water bodies,
e) 50 feet between wetted area and public right of ways,
f) 100 feet between treatment/storage units and any wells, and
g) 50 feet between treatment units and property Iines.
Some of the buffers specified above may not have been included in previous permits for this waste
treatment and disposal system. These buffers are not intended to prohibit or prevent modifications,
which are required by the Division, to improve performance of the existing treatment facility. These
buffers do, however, apply to modifications of the treatment and disposal facilities that are for the
purpose of increasing the flow that is tributary to the facility. These buffers do apply to any
expansion or modification of the irrigation areas and apply in instances in which the sale of property
would cause any of the buffers now complied with, for the treatment and disposal facilities, to be
violated. The applicant is advised that any modifications to the existing facilities will require a permit
modification.
2

11. OPERATION AND MAINTENANCE REQUIREMENTS
L The facilities shall be properly maintained and operated at all times.
2. Upon classification of the wastewater treatment and irrigation facilities by the Water Pollution
Control System Operators Certification Commission (WPCSOCQ, the Permittee shall designate and
employ a certified operator to be in responsible charge (ORC) and one or more certified operator(s) to
be back-up ORC(s) of the facilities in accordance with 15A NCAC 8G .0201. The ORC shall visit
the facilities in accordance with 15A NCAC 8G .0204 or as specified in this permit and shall comply
with all other conditions specified in these rules.
Inclement weather shall not affect the spray irrigation of wastewater unless the ground is in a
condition that will cause runoff on Fields A, C, D, E, F, G, H, I and J. During such events, all
wastewater shall be diverted to Field B until the remaining fields are suitable for irrigation. If an upset
condition occurs in Field B, resulting in an overflow or discharge of wastewater, the Permittee shall
contact the Division. The Permittee shall also conduct a study to determine how and why this upset
condition occurred, and shall take the necessary steps to ensure that future problems do not arise. The
study and its recommendations shall• be submitted to both the Regional and Central Offices upon
completion.
4. The application, instantaneous and PAN loading rates shall not exceed the following:
Field - Zone
Area Annual Loading Rate
(acres) (in/yr)
Instantaneous Loading Rate
(as limited by design)
(in/hr)
Calculated annual
PAN Loading Rate
(lbs/acre)
A
83.35 156
n/a
350
B
8.60 156
n/a
350
C
58.42 156
n/a
350
D
35.34 156
n/a
350
E
54.59 156
n/a
350
F
39.49 156
n/a
350
G
33.35 156
n/a
350
H
62.39 156
n/a
350
I
30.0 156
n/a
350
J-1
4.80 91
0.5
220
J-2
4.81 91
0.5
220
J-3
4.44 91
0.5
220
J-4
3.71 91
0.5
220
J-5
6.26 91
0.5
220
J-6
5.52 91
0.5
220
J-7
5.37 91
0.5
220
J-8
4.78 51
0.5
220
J-9
5.75 51
0.5
220
J-10
4.88 91
0.5
220
J-1 I
3.64 51
0.5
220
Total
3

S. A suitable year round vegetative cover shall be maintained.
b. Adequate measures shall be taken to prevent wastewater runoff from the irrigation field.
7. The facilities shall be effectively maintained and operated as a non -discharge system to prevent the
discharge of any wastewater resulting from the operation of this facility.
8. No type of wastewater other than that from the Maxton Plant and Silgan Can Company shall be
irrigated onto the irrigation area.
9. No traffic or equipment shall be allowed on the disposal area except while installation occurs or while
normal maintenance is being performed.
10. Public access to the land application sites shall be controlled during active site use. Such controls
may include the posting of signs showing the activities being conducted at each site.
11I. MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, soil or plant tissue analyses) deemed
necessary by the Division to insure surface and ground water protection will be established and an
acceptable sampling reporting: schedule shall be followed.
2. Influent flow shall be continuously monitored and daily flow values shall be reported on Form
NDMR.
The Permittee shall install an appropriate flow measurement device consistent with approved
engineering and scientific practices to ensure the accuracy and reliability of influent flow
measurement. Flow measurement devices selected shall be capable of measuring flows with a
maximum deviation of less than 10 percent from true flow, accurately calibrated at a minimum of
once per year, and maintained to ensure that the accuracy of the measurements is consistent with the
accepted capability of that type of device. The Permittee shall keep records of flow measurement
device calibration on file for a period of at least three years. At a minimum, data to be included in
this documentation shall be:
a. Date of flow measurement device calibration
b. Name of person performing calibration
c. Percent from true flow
3. The effluent from the subject facilities shall be monitored by the Permittee at a point prior to
irrigation every month for the following parameters:
NH3 as N
NO2-NO3
Nickel
BOD5
TKN
Total Phosphorous
TSS
Sodium
Magnesium
pH
Calcium
Cadmium
Flow (GPD)
Copper
Zinc
Sodium Adsorption Ratio by Calculation
I Plant Available Nitrogen by Calculation
4

4. The Permittee tracking the amount of wastewater disposed shall maintain adequate records. These
records shall include, but are not necessarily limited to, the following information:
a. Date of irrigation,
b. Volume of wastewater irrigated,
c. Field irrigated,
d. Length of time field is irrigated,
e. Continuous weekly, monthly, and year-to-date hydraulic (inches/acre) loadings for each field,
f. Weather conditions, and
g. Maintenance of cover crops.
5. An agricultural expert or licensed agronomist shall submit an annual report to the Division, and shall
include at a minimum:
a. Total volume of effluent applied to each field;
b. Types and quantities of nutrient additives applied to each field;
c. Overall evaluation of each field;
d. Annual maintenance and management practices that have been performed (i.e., weed control,
surface aeration, deep aeration, crop removal and final destination, plant tissue analysis of hay
crop, evaluation of soil test, actual PAN application (acre/yr) and equipment repair.
6. Three (3) copies of all monitoring data [as specified in Conditions I1I(2) and 1II(3)] on FormNDMR-
1 and three (3) copies of all operation and disposal records [as specified in Condition I11(4)] on Form
NDAR-1 shall be submitted on or before the last day of the following month. All information shall
be submitted to the following address:
NC Division of Water Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
7. An annual representative soils analysis (Standard Soil Fertility Analysis) shall be conducted on each
irrigation field and the results maintained on file by the Permittee for a minimum of five years. The
Standard Soil Fertility Analysis shall include, but is not necessarily limited to, the following
parameters:
Acidity
Manganese
Potassium
Calcium
Percent Humic Matter
Sodium
Copper
pH
Zinc
Magnesium
Base Saturation (by calculation)
Phosphorus
Cation Exchange Capacity
Exchangeable Sodium Percentage

8. Noncompliance Notification:
The Permittee shall report by telephone to the Fayetteville Regional Office, telephone number (910)
486-1541, as soon as possible, but in no case more than 24 hours or on the next working day
following the occurrence or first knowledge of the occurrence of any of the following:
a. Any occurrence at the wastewater treatment facility which results in the treatment of significant
amounts of wastes which are abnormal in quantity or characteristic, such as the dumping of the
contents of a sludge digester; the known passage of a slug of hazardous substance through the
facility; or any other unusual circumstances.
b. Any process unit failure, due to known or unknown reasons, that render the facility incapable of
adequate wastewater treatment such as mechanical or electrical failures of pumps, aerators,
compressors, etc.
c. Any failure of a pumping station, sewer line, or treatment facility resulting in a by-pass directly to
receiving waters without treatment of all or any portion of the influent to such station or facility.
d. Any time that self -monitoring information indicates that the facility has gone out of compliance
with its permit limitations.
Occurrences outside normal business hours may also be reported to the Division's Emergency
Response personnel at telephone number [phone], [phone], or [phone].
Persons reporting such occurrences by telephone shall also file a written report in letter form within
five (5) days following first knowledge of the occurrence. This report must outline the actions taken
or proposed to be taken to ensure that the problem does not recur.
IV. GROUNDWATER REQUIREMENTS
1. Well Construction / Abandonment Criteria:
a. Within ninety (90) days of permit issuance, two (2) monitor wells designated as MW-11 and
MW-12 shall be installed in the vicinity of Irrigation Field "J" to monitor groundwater quality.
The wells shall be constructed such that the water level in the well is never above or below the
screened (open) portion of the well at any time during the year. The general location and name
for each well is marked on Figure 1. Each monitoring well shall be located at the Review
boundary, constructed in accordance with this permit, and approved by the Fayetteville Regional
Office.
b. A North Carolina Certified Well Contractor, the property owner, or the property lessee according
to General Statutes 87-98.4(b) (2) must construct the well(s). If the construction is not performed
by a certified well contractor, the property owner or lessee must physically perform the actual
well construction activities, and the well(s) must be constructed according to the North Carolina
Well Construction Standards (15A NCAC 2C .0108) and the local county rules.
c. The Fayetteville Regional Office, telephone number [phone], shall be notified at least
forty-eight (48) hours prior to the construction of any monitoring well so that an inspection can be
made of the monitoring well location. Such notification to the regional groundwater supervisor
shall be made during the normal office hours from 8:00 a.m. until 5:00 p.m. on Monday through
Friday, excluding state holidays.
d. Within thirty (30) days of completion of all well construction activities, a certification must be
received from a professional engineer or a licensed geologist certifying that the monitoring wells
are located according to this permit.

2_ Sampling Criteria:.
a. The new monitor wells designated as MW-11 and MW-12 (depicted on Figure 1) shall be
sampled initially after construction and thereafter every March, July, and November for the
parameters listed below. Existing monitor wells MW-1, MW-2, MW-3, MW-4, MW-5, MW-6,
MW-8 and MW-9 shall be sampled every March, July, and November for the parameters listed
below. Prior to sampling the parameters, the measurement of water levels must be taken. The
depth to water in each well shall be measured from the surveyed point on the top of the casing.
The measuring points (top of well casing) of all monitoring wells shall be surveyed relative to a
common datum.
Water Level
Chloride
Total Organic Carbon JOC)
Nitrate (NOa-N)
Total Phosphorus
Total Ammonia Nitrogen (NH3-N)
pH
Total Dissolved Solids (TDS)
b. For Total Organic Carbon (TOC), if concentrations greater than 10 mg/l are detected in any
down -gradient monitoring well, additional sampling and analysis must be conducted to
identify the individual constituents comprising this TOC concentration. If the TOC
concentration as measured in the background monitor well exceeds 10 Ing/l, this
concentration will be taken to represent the naturally occurring TOC concentration. Any
exceedances of this naturally occurring TOC concentration in the down -gradient wells shall
be subject to the additional sampling and analysis as described above.
3. Reporting / Documentation:
a. All reports and documentation (GW-1, GW-30, GW-59) shall be mailed to the following address:
Aquifer Protection Section
Permits and Compliance Unit
1617 Mail Service Center
Raleigh, NC 27699-1636
Updated blank forms (GW-1, GW-30, GW-59) may be downloaded at the following website
httpR////gw.ehnr_state.nc.us/ or requested from the address mentioned above.
b. For the initial sampling of the welI(s), the permittee shall submit a copy of the GW-1 Form (Well
Construction Record) with the Compliance Monitoring Form (GW-59) for each well to the
address listed in the "Reporting / Documentation" section of the Groundwater Requirements.
Initial Compliance Monitoring Forms that do not include copies of the GW-1 form may be
returned to the permittee without being processed. Failure to submit these forms as required by
this permit may result in the initiation of enforcement activities pursuant to NC General Statutes
143-215.6A.
c. The results of the sampling and analysis must be received on Form GW-59 (Groundwater Quality
Monitoring: Compliance Report Form) by the Aquifer Protection Section (address listed in the
"Reporting / Documentation" section of the Groundwater Requirements), on or before the last
working day of the month following the sampling month. The data of all groundwater sampling
analyses required by the permit conditions must be reported using the most recent GW-59 form
along with attached copies of the laboratory analyses.

d. Within sixty (60) days of completion of [the I all] monitoring well(s), the permittee shall submit
two original copies of a scaled site map (scale no greater than 1"=100); however, special
provisions may be granted upon prior approval for large properties. The map(s) must include the
following information:
1) The location and identity of each monitoring well.
2) The location of major components of the waste disposal system.
3) The location of property boundaries within 500 feet of the disposal area(s).
4) The latitude and longitude of the established horizontal control monument.
5) The elevation of the top of the well casing (which shall be known as the "measuring point")
relative to a common datum.
6) The depth of water below the measuring point at the time the measuring point is established.
7) The location of Review and Compliance boundaries.
8) The date the map is prepared and/or revised.
Control monuments shall be installed in such a manner and made of such materials that the
monument will not be destroyed due to activities that may take place on the property. Maps and
any supporting documentation shall be sent to the Aquifer Protection Section as addressed in the
"Reporting / Documentation" above.
The pemittee is responsible for the geographic accuracy of any map submitted, however
produced.
4. Vertical Separation Requirements:
Industrial waste shall not be applied or discharged onto or below the land surface when the vertical
separation between the waste and the seasonal high water table is at less than three (3) feet, unless the
Permittee has demonstrated to the Director or his delegate, by using predictive calculations or
modeling methods acceptable to the Director or his delegate, that such placement will not result in the
contravention of classified groundwater standards.
5. Applicable Boundaries:
a. The COMPLIANCE BOUNDARY for the disposal system is specified by regulations in 15A
NCAC 2L, Groundwater Classifications and Standards. The Compliance Boundary is for the
disposal system individually permitted prior to December 31, 1983 consisting of Fields A, B, C,
D, and E is established at either 500 feet from the waste disposal area, or at the property
boundary, whichever is closest to the waste disposal area. An exceedance of Groundwater
Quality Standards at or beyond the Compliance Boundary is subject to remediation action
according to 15A MCAC 2L .0106(d)(2).
b. The COMPLIANCE BOUNDARY for the disposal system is specified by regulations in 15A
NCAC 2L, Groundwater Classifications and Standards. The Compliance Boundary is for the
disposal system individually permitted after December 31, 1983 consisting of Fields F, 0, I and J
is established at either 250 feet from the waste disposal area, or 50 feet within the property
boundary, whichever is closest to the waste disposal area. An exceedance of Groundwater
Quality Standards at or beyond the Compliance Boundary is subject to remediation action
according to 15A MCAC 2L .0106(d)(2).
c. The REVIEW BOUNDARY is established around the disposal systems midway between the
Compliance Boundary and the perimeter of the waste disposal area. Any exceedance of standards
at the Review Boundary shall require action in accordance with 15A NCAC 2L .0106(d)(1).

V. INSPECTIONS
1. Adequate inspection, maintenance, and cleaning shall be provided by the Permittee to insure proper
operation of the subject facilities.
2. The Permittee or his designee shall inspect the wastewater treatment and disposal facilities weekly to
prevent malfunctions and deterioration, operator errors and discharges which may cause or lead to the
release of wastes to the environment, a threat to human health, or a nuisance. The Permittee shall
keep an inspection log or surnmary including at least the date and time of inspection, observations
made, and any .maintenance, repairs, or corrective actions taken by the Permittee. This log of
inspections shall be maintained by the Permittee for a period of three years from the date of the
inspection and shall be made available upon request to the Division or other permitting authority.
3. Any duly authorized officer, employee, or representative of the Division may, upon presentation of
credentials, enter and inspect any property, premises or place on or related to the disposal site or
facility at any reasonable time for the purpose of determining compliance with this permit; may
inspect or copy any records that must be maintained under the terms and conditions of this permit,
and may obtain samples of groundwater, surface water, or leachate.
VI. GENERAL CONDITIONS
This permit shall become voidable unless the facilities are constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
2. This permit is effective only with respect to the nature and volume of wastes described in the
application and other supporting data.
3. This permit is not transferable. In the event there is a desire for the facilities to change ownership, or
there is a name change of the Permittee, a formal permit request must be submitted to the Division
accompanied by an application fee, documentation from the parties involved, and other supporting
materials as may be appropriate. The approval of this request will be considered on its merits and
may or may not be approved.
4. Failure to abide by the conditions and limitations contained in this pertnit may subject the Permittee
to an enforcement action by the Division in accordance with North Carolina General Statute 143-
215.6A to 143-215.6C.
5. The issuance of this permit does not exempt the Permittee from complying with any and all statutes,
rules, regulations, or ordinances which may be imposed by other government agencies (local, state,
and federal) which have jurisdiction, including but not limited to applicable river buffer rules in 15A
NCAC 2B .0200, erosion and sedimentation control requirements in 15A NCAC Chapter 4 and under
the Division's General Permit NCGO10000, and any requirements pertaining to wetlands under 15A
NCAC 2B .0200 and 2H .0500.
6. The Permittee shall retain a set of approved plans and specifications for the life of the project.
7. The Permittee must pay the annual administering and compliance fee within thirty (30) days after
being billed by the Division. Failure to pay the fee accordingly may cause the Division to initiate
action to revoke this permit as specified by 15A NCAC 2H .0205 (c)(4).
8. The Permittee, at least six (6) months prior to the expiration of this permit, shall request its extension.
Upon receipt of the request, the Commission will review the adequacy of the facilities described
therein, and if warranted, will extend the permit for such period of time and under such conditions
and limitations as it may deem appropriate.

9. The subject wastewater treatment and disposal facilities shall be connected to an operational publicly
owned wastewater collection system within 180 days of its availability to the subject facilities, if the
subject wastewater treatment or disposal facilities are in noncompliance with the terms and conditions
of this non -discharge permit or the governing statutes or regulations. Prior to the initiation of these
connection activities, appropriate approval must be received froth this Division.
Permit issued this the loth day of February, 2005
NORTH CA LINA ENV R NMENTAL MANAGEMENT COMMISSION
Alan W. Klimek, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission
Permit Number WQ0003626
10

Permit No. WQ0003626
February 10, 2005
ENGINEER'S CERTIFICATION
Partial Final
I, , as a duly registered Professional Engineer in the State
of North Carolina, having been authorized to observe (periodically, weekly, full time) the construction of
the project,
Project Name
Location and County
for the Permittee hereby state that, to the best of my abilities, due care and diligence was used in the
observation of the construction such that the construction was observed to be built within substantial
compliance and intent of this permit, the approved plans and specifications, and other supporting
materials.
Signature
Date
Registration No.
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