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HomeMy WebLinkAboutWQ0039473_Application_20230210DWR State of North Carolina Department of Environmental Quality Division of Water Resources Division of Water Resources 15A NCAC 02T .0500 — WASTEWATER IRRIGATION SYSTEM — RENEWAL FORM: WWIS-R 02-21 Pursuant to 15A NCAC 02T .0107(b), if the application does not include all required information and the necessary supporting documentation, the application shall be returned. The application and attachments shall be prepared in accordance with 15A NCAC 02T .0100, 15A NCAC 02T .0500, and Division Policies. For more information, visit the Water Quality Permitting Section's Non -Discharge Branch website. The Applicant shall submit an electronic copy of the application and attachments uploaded as a single Portable Document Format (PDF) file to httt)s://edocs.deci.nc.2ov/Forms/NonDischar2e-Branch-Submittal- Form-Ver2, or emailed to Non-Dischar2e.Reuorts(dncdenr.2ov if less than 20 megabytes (MB). SECTION I — APPLICANT INFORMATION I. Applicant: Atkinson Milling Company 2. Permit No.: WQ0039473 3. Signature authority: Andrew D. Wheeler Phone number: (919) 631-7572 Select Title: Email: awheelerd@gmail.com 4. Mailing address: 914 Bluegrass Road City: Selma State: NC Zip: 27576- 5. Contact person: Andrew D. Wheeler Primary phone number: (919) 631-7572 Select Email: awheelerd@gmail.com Secondary phone number: ( ) - Select SECTION II — FACILITY INFORMATION 1. Physical address: 95 Atkinson Mill Road County: Johnston Parcel No.: 262900-08-1710 City: Selma 2. Treatment facility coordinates to the sixth decimal degree: Latitude: 35.0° Longitude:-78.2566' State: NC Zip: 27576- Method: Map interpretation by extraction SECTION III — FLOW INFORMATION 1. Permitted flow: 1428 GPD (The maximum allowable flow based on what has been permitted) 2. As -built flow: 1428 GPD (The maximum allowable flow based on what has been constructed) 3. Average flow: GPD (The average of all reported flows on the previous calendar year's NDMRs) 4. Hydraulic capacity: % (Divide the average flow in Item 3 by the As -built flow in Item 2) 5. Wastewater composition: Domestic : % Industrial: 100 % Stormwater: % SECTION IV — BILLING INFORMATION 1. Billing address: 95 Atkinson Mill Road City: Selma State: NC Zip: 27576- 2. Verify the Applicant does not have any overdue annual fees: https:Hdeq.nc. gov/about/divisions/water-resources/water-resources-permits/wq-cpavments Pursuant to 15A NCAC 02T .0120(c), permits for renewing facilities shall not be granted if the Applicant or any affiliation has an unpaid annual fee. FORM: WWIS-R 02-21 Page 1 of 6 SECTION V — OPERATOR IN RESPONSIBLE CHARGE (ORC) INFORMATION 1. ORC: Andrew Davis Wheeler Grade: Certification No.: 1006226 Mailing address: 95 Atkinson Mill Road City: Selma State: NC Zip: 27576- Phone number: (919) 965-3547 Select Email glenn@atkinsonmilling.com 2. Back -Up ORC: Randall Jarrell Grade: Certification No.: 23925 Mailing address: 705 Sanford Road City: Pittsboro State: NC Zip: 27312- Phone number: (919) 210-2500 Select Email: Biowater@aol.com SECTION VI JVPEN-ATMILPHERE STRUCTURES 1. List all open -atmosphere treatment and storage structures associated with the renewing permit. Attach additional sheets if necessary. Type Parcel No. Volume (gal) Liner Type Freeboard (ft) Latitude Longitude Select Select 0- ° Select Select 0- ° Select Select 0- ° Select Select 0- ° SECTION VII — RELATED PERMITS 1. List all wastewater permits (i.e., sewer, collection system, NPDES, residuals) that have interactions with the renewing permit. Attach additional sheets if necessary. Permit Type Permit No. Relationship Type Select Select Select Select Select Select Select Select SECTION VIII — MONITORING WELLS 1. List all groundwater monitoring wells associated with the renewing permit. Attach additional sheets if necessary. Well Name Parcel No. Status Gradient Location Latitude Longitude Select Select Select ° - ° Select Select Select ° - ° Select Select Select ° - ° Select Select Select ° - ° Select Select Select ° - ° Select Select Select ° - ° Select Select Select ° - ° Select Select Select ° - ° Select Select Select ° - ° Select Select Select ° - ° Select Select Select ° - ° FORM: WWIS-R 02-21 Page 2 of 6 SECTION IX — IRRIGATION FIELDS 1. List all irrigation fields associated with the renewing permit. Attach additional sheets if necessary. Field County Parcel No. Deeded Owner Area Cover Crop Latitude Longitude 1 Johnston I IN04017F Glenn Ray Wheeler, Jr. 2.10 Bermuda 35.671880 -78.25660 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Total Acreage: 2.1 FORM: WWIS-R 02-21 Page 3 of 6 ATTACHMENT A — SITE MAP . Was the facility originally permitted or had a major modification issued after September 1, 2006? ® Yes — Pursuant to 15A NCAC 02T .0105(d), submit a site map pursuant to the requirements in 15A NCAC 02T .0504(d). These requirements are: ® A scaled map of the site with topographic contour intervals not exceeding 10 feet or 25 percent of total site relief and showing all facility -related structures and fences within the wastewater treatment, storage, and irrigation areas. ® Soil mapping units shown on all irrigation sites. ® The location of all wells (including usage and construction details if available), streams (ephemeral, intermittent, and perennial), springs, lakes, ponds, and other surface drainage features within 500 feet of all wastewater treatment, storage, and irrigation sites. ® Delineation of the compliance and review boundaries per 15A NCAC 02L .0107 and .0108, and 15A NCAC 02T .0506(c) if applicable. ® Setbacks as required by 15A NCAC 02T .0506. ® Site property boundaries within 500 feet of all wastewater treatment, storage, and irrigation sites. ® All habitable residences or places of public assembly within 500 feet of all treatment, storage, and irrigation sites. ❑ No — Skip Attachment A. ATTACHMEN — SIGNATURE AUTHORITY DELEGATION Does the signature authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)? ❑ Yes — Skip Attachment B. ® No — Submit a delegation letter pursuant to 15A NCAC 02T .0106(c) authorizing the signature authority to sign. ATTACHMENT C — FLOW REDUCTION Does the existing permit include an approved flow reduction? ❑ Yes — Submit a copy of the flow reduction approval letter, as well as the measured monthly average amount of wastewater flow contributed per unit for the 12 months prior to permit renewal. If any of these monthly averages are within 20% of the approved flow reduction value, the Permittee shall provide a reevaluation of the reduced flow value pursuant to the requirements in 15A NCAC 02T .0114(f). ® No — Skip Attachment C. W� ATTACHMENT D — CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY A Is the Applicant a Privately -Owned Public Utility? ❑ Yes — Pursuant to 15A NCAC 02T .0115(a)(1), submit the Certificate of Public Convenience and Necessity from the North Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise. ® No — Skip Attachment D. ATTACHMENT E — OPERATIONAL AGREEMENT I Is the Applicant a Home/Property Owners' Association or Developer of Lots to be Sold? ❑ Yes (Home/Property Owners' Association) — Pursuant to 15A NCAC 02T .0115(a)(2), submit an executed Operational Agreement (FORM: HOA). Pursuant to 15A NCAC 02T .0115(c), if the applicant is a legally formed Homeowners' or Property Owner's Association, submit a copy of the Articles of Incorporation, Declarations, and By-laws. ❑ Yes (Developer of Lots to be Sold) — Pursuant to 15A NCAC 02T .0115(a)(2), submit an executed Operational Agreement (FORM: DEW Pursuant to 15A NCAC 02T .0115(b), if the applicant is a developer of lots to be sold, submit a copy of the Articles of Incorporation, Declarations, and By-laws. ® No — Skip Attachment E. FORM: WWIS-R 02-21 Page 4 of 6 ATTACHMENT F - DEMONSTRATION OF FUTURE WASTEWATER TREATMENT CAPACITIES Is the applicant a municipality, county, sanitary district, or public utility? ❑ Yes — Proceed to the next question. ® No — Skip Attachment F. Does the hydraulic capacity in Section III, Item 4 exceed 70%? ❑ Yes (the hydraulic capacity is greater than 70%, but less than 80%) — Pursuant to 15A NCAC 02T .0118(1), prior to exceeding 80 percent of the system's permitted hydraulic capacity (based on the average flow during the last calendar year), the permittee shall submit an engineering evaluation of their future wastewater treatment, utilization, and disposal needs. This evaluation shall outline plans for meeting future wastewater treatment, utilization, or disposal needs by either expansion of the existing system, elimination or reduction of extraneous flows, or water conservation and shall include the source of funding for the improvements. If expansion is not proposed or is proposed for a later date, a justification shall be made that wastewater treatment needs will be met based on past growth records and future growth projections, and as appropriate, shall include conservation plans or other measures to achieve waste flow reductions. ❑ Yes (the hydraulic capacity greater than 80%) — Proceed to the next question. ❑ No — Skip Attachment F. If answered Yes above, does the hydraulic capacity in Section III, Item 4 exceed 80%? ❑ Yes (the hydraulic capacity is greater than 80%) — Pursuant to 15A NCAC 02T .0118(2), prior to exceeding 90 percent of the system's permitted hydraulic capacity (based on the average flow during the last calendar year), the permittee shall obtain all permits needed for the expansion of the wastewater treatment, utilization, or disposal system and, if construction is needed, submit final plans and specifications for expansion, including a construction schedule. If expansion is not proposed or is proposed for a later date, a justification shall be made that wastewater treatment needs will be met based on past growth records and future growth projections, and as appropriate, shall include conservation plans or other specific measures to achieve waste flow reductions. ❑ No — Skip Attachment F. ACHMEN - EASEMENT, ENCIFACHMENT, AND JEASE AJZEEMENTSMI Does the Permittee own all of the land associated with the wastewater collection, treatment, conveyance, and irrigation system? ® Yes — Skip Attachment G. ❑ No — Pursuant to 15A NCAC 02T .0116(c), provide a copy of all easements, lease agreements, and encroachment agreements allowing the Permittee to operate and maintain the wastewater collection, treatment, conveyance, and irrigation system on property not owned by the Permittee. ATTACHMENT H - AFFILIATIONS Are the Permittee's affiliations of record correct? Check affiliations. ® Yes — Skip Attachment H. ❑ No — Provide the corrected affiliations and their contact information. ATTACHMENT I - COMPLIANCE SCHEDULES Does the existing permit include any Compliance Schedules? (See Section I of the most recently issued permit) ® Yes — Submit documentation that the compliance schedules have been met. ❑ No — Skip Attachment I. I ATTACHMENT J - CIVIL PENALTIES AND OUTSTANDING VIOLATIONS I Does the Permittee have any existing civil penalties or outstanding violations? ❑ Yes (civil penalties) — Submit payment for the civil penalty, or proof of remission request. ❑ Yes (violations) — Submit a copy of your response to the Notice of Violation. ® No — Skip Attachment J. FORM: WWIS-R 02-21 Page 5 of 6 A'Y"i'rA{:'I•IME.NT K INI)U.YFRL%L N ASTEIVA'mR Does lltc wastewater composition i11 SCCti011 i11, Iteilt 5 include any industrial wastewater? N Yes - Proceed to the next queslion. ❑ No - Skip Attachment K. Has the nature ofthc industrial wastewater changed since the last permit issuance (i.c,. changes in industrial process, introduction of now materials or chemicals, etc.)? ❑ Yes - Provide a chemical analysis of the wastewater pursuant to the requirements in 15A NCAC 021' .0504(h . Provide an overview of the manufacturing process; an inventory of all clten:icaI and biological materials used in the manufacturing process; and an overview of the cleaning and treatment tnethodoIogy. ® No - Provide an overview of the manufacturing, process; an inventory of all chemical and biological materials used in the manufacturing process; and an oven•iew of the cleaning and treatment meth odoIofy, AVITACIfMF.:N ' L SETHAJCK Will IVERS Does [lie existing permit include setback waivers? Yes - Pursuant to 15A NCAC 02T .0506fd}, provide setbacks waivers that have been written, notarimd, signed by all panics involved, and recorded wills the county Register of Deeds Waivers involving tiro compliance boundary shall be in accordance with 15A NCAC 021L .0107. ( ,i No - Skip Attachment L. API'I..ICrIN'i" S (1,11TiFICATION 1, �'`^� [A' ke10 `e-- _ attest that this application (Signature authority's name as noted in Section 1, Item 3) has been reviewed by the and is accurate and complete to tiie lest of my knowledge. € understand that if all required Darts of this application Trackage are not completed, and that if all required supporting information and attachments are not included, this application package will be returned as incomplete. I hu-ther certify pursuant to 1 SA NCAC (12T .01201 b), that the applicant, or any parent. subsidiary, or other affiliate of the applicant Itas.- not been convicted of environmental crimes ur_dcr; not previously abandoned a wastewater treatment facility without properly closing; the facility; not paid a civil penalty; not been compliant with any compliance schedule ill a peMnit, settlement agreement, or order; not paid an alumal fec. Note: 1'lie Applicant's Cerliiication shall be signed pursuant to 15A NCAC 02T .0106(b . An altentatc person may be delegated as the signing official if a letter is provided pursuant to 15A NCAC 02T .010h(c). Pursuant to § 14+-215.6A and § 143-215.6B, any person who knowin Rly makes any false statement, presentation, or certification in any application package shall be guilty of a Class 2 misdemeanor, ich ay include a h tr tt !o c, crd 5lG 00 as well as civil penalties up trrod� S25,000 per violation. Signature: Date' Tl1E COMPLETED APPLICATION AND ATTACHMMrs SHALL BE sunmj'1"rED AS A SINGLE PDF FILE VIIA: Email: Non-Discharec. Rcport(a nedrnr.g!)v Laserfiche Upload; Ittr�s:Ilcdacs.deq,rtc.gt►�•IFnrmsl,�l rFtri?isrlsarge-Sea nclt- 4ubmittal-Form-l'er2 FORM- W W 1S-R 02-21 Page 6 off+ Process Description The Atkinson Milling Company WWTF processes wastewater created by the large-scale production of frozen, packaged hushpuppies. As such, the primary constituents of the wastewater are batter residue (cornmeal, dairy, some fats) from mixing and processing vessels, along with water and detergents from cleanup and washdown of equipment. As pressure washers and very hot water are used for much of the cleanup, the amount of detergent is quite low. Used cooking oil from the large conveyor fryer is recovered and not introduced to the WWTF. The treatment system consists of gravity settling, and anaerobic biological treatment by naturally occurring bacteria. The remaining chemical(s) used are hydroxides for pH adjustment. These can be sodium hydroxide, calcium hydroxide or magnesium hydroxide. The primary determinations for selection are cost and ease of incorporation into the wastewater stream, but substitution can be made to accommodate land application area parameters (primarily the sodium adsorption ratio, SAR). 0 v6 L,s r o« a«.a 1� k r �IiLL .,s r 15!!L y.L Portion of NC DOT Johnston County Map Sheet GRAPHIC SCALE s� Atkinson Milling Company Site �r !E ..ptrw�t..y SEAL 025W Q. y''�' � p��' l5 W►t4' GRAPHIC SCALE Key Stream or Gulley �� Pencellne rc + e�.Ame rryw ua.cb.d�a �w ❑ +zs ze❑ s❑o io❑❑ Property Line �. Sprinker Atkinson Milling Company, Compliance Boundary Storage Residual Application Site - ( C IN FEET Resew Boundary Q l"n E61 f.'ndlNHANd and NJnlInl - - -- — - Application Area • Well Pipeline C F a B PaD a 7� App Ar (total) 2.0 ac es Goy i' Tn Soils Key WaB Wagram Loamy Sand 0%-6% GRAPHIC SCALE Bb Bibb Sandy Loam (freq. flooded) 0 125 255 5W 1 p McB Maralboro-Cecil Complex 2%-8% IN FEET > AaA Altavista Fine Sandy Loam 0%-2% StA State Sandy Loam 0%-3% (occ. flooded) Aft N Portion of Johnston County GTS Soils M (7/10/2017) �-.iw, State of North Carolina Department of Environmental (duality Division of Water Resources NON -DISCHARGE WASTWATER SYSTEM WAIVER ±�AGREEM�ENT TO WAIVESETBACKS AS REQUIRED BY Glenn R. INtteeEer� �siNdCer�.a p 5tlti(a), .0506(1i), .Q60t"i(a), .070b(a) AN D .141i1(i(a) 1, Milling Company, Inc.) certify that I am a deeded owner of the property located at: Address: 95 Atkinson Mil{ Rd Parcel No.: 11NO4 117E City: Selma State: NC Zip Code. 27576 County: Johnston Furthermore, I certify that I am authorized to snake decisions regarding this property, and that I do hereby agree that the setback distances cited below be granted to the Applicant/Permittee listed on the following, page. I understand the setback requirements set forth in 1SA NCAC 02T. For the parcel identified above, I consent to a reduced setback from 250 feet to 100 feet., thereby allowing the application of wastewater effluent as near as 1�feet from my property line. ❑ I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified above, I consent to a reduced setback from feet to feet, thereby allowing the application of wastewater effluent as near as feet from my residence. ❑ I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified above, t consent to a reduced setback from feet to feet, thereby allowing the construction cif wastewater treatment and storage units as near as ,,,,_,,,feet from my property line. ❑ I understand the setback requirements set fortis in 15A NCAC 021'. For the parcel Identified alcove, 1 consent to a reduced setback from feet to feet, (hereby allowing the construction o wastewater treatment and storage units as near as feet from my residence. Signature: —Date:- FORM: NDWSW03-17 € age l o172 Applicant/Permittee: Andrew Q. Wheeler Address: 914 Bluegrass Rd Parcel No.: 11NO4017F City: Selma State: NC Zip Co Ele: 27576 County: Johnston NORTH CAROLINA, Xa6M Cjah COUNTY 1, , a Notary Public for :nO b.t� County, forth Carolina, do hereby certify that r )pnim 1l�heJ%r ersonally appeared before me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal, this the _,,L day of ,Ado U5+ SEAL A. , dujz: PEGGY UTT Signatumof NotaryPublic NOTARY PUBLIC My cmmission 80-es a 3 Z JOHNSTON COUNTY STATE OF NORTH CARt LIMA Once notarized, this form shall be recorded at the Register of Deeds in the county or counties in which the described properties are located. k copy of the recorded waiver shall be sent to the following address: Division of Water Resources Water Quality Permitting Section 1617 Mail Service Center Raleigh, North Carolina 27699-1 G 17 FORM: NDWSW 03.17 Page 2 or2 State of North Carolina Department of Environmental Quality Division of Water Resources NON -DISCHARGE WASTWATER SYSTEM WAIVER AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY 15A NCAC 02T .0506(a), .0506(b), .0606(a), .0706(a) AND .1006(a) I, Glenn €t. Wheeler , certify that I am a deeded owner of the property located at: Address: 281 Atkinson Mill Rd Parcel No.: 12N04017F City: Selma State: NC Zip Code: 27-176 County: Johnston Furthermore, I certify that I ain authorized to snake decisions regarding this property, and that I do hereby agree that the setback distances cited below be Ranted to the ApplicantfPermittee listed on the following page. ❑ I understand the setback requirements set forth In 15A NCAC 02T. For the parcel idenieiied above, I consent to a reduced setback from feet to feet, thereby allowing the application of wastewater effluent as near as feet from my property line. 0 I understated the setback requirements set forth In 1 $A NCAC 02T. For the parcel Identified above, I consent to a reduced setback from 200 feet to 100 feet, thereby allowing the application of wastewater effluent as near as 10'(r%et from my residence. ❑ I understand the setback requirements set forth in 15A NCAC 02T. For the parcel Identified above, I consent to a reduced setback from feet to feet, thereby allowing the construction of wastewater treatment and storage units as near asfeet from my property line. ❑ I understand the setback requirements set forth In ISA NCAC 02T. For the parcel identified above, I consent to a reduced setback from feet to feet, thereby allowing the construction A wastewater treatment and storage units as near as feet from my residence. signature, ©ate: i-�"��� FORM: Ni2VtFSW 03.17 Page 1 of" App€icant/Pennittee: Andrew D. Wheeler Address: 914 Bluegrass Rd Parcel No.: 12ND4017F City: Selma State: NC Zip Cade: 27576 County: Johnston NORTH CAROLINA, COUNTY I, q U 44 , a Notary Publie %r .J D j0,.. County, North Carolina, do hereby certify that personally appeared before me this day and acknowledged the due execution of the foregoing instrument. ► fitness my hand and official seal, this the __I day of EL SEAT. PEGGY UTT NOTARY PUBLIC JOHNSTON COUNTY STATE OF NORTH CAROL€NA Signature of Notary Public Once notarized, this farm shall be recorded at the Register of deeds in the county or counties in which the described properties are located. A copy of the recorded waiver shall be sent to the following address: Division of Water Resources Water Quality Permitting Section 1617 Mail Service Center Raleigh, North Carolina 27699-1617 FORM: NDWSW 03-17 Page 2 of 2 WATER POLLUTION CONTROL. SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC) NCAC 1.SA 8G .0201 Press TAB to enter Information Permittee Owner/Officer Name: Glenn Wheeler Jr Mailing Address: 95 Atkinson Mill _Road _ _ _ _ _ _ _ Phone: 9199653547 city: Selma state: NC zip: 27576 (c Email Address: glennDatkinsonmillinq.eom _ Signature: Date: Facility Name: Atkinson Millinq WWTF Permit ll WQ0039473 County: YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM: Facility Type: SI Facility Grade: Select��^^� OPERATOR IN RESPONSIBLE CHARGE (ORC) Print Full Name: Andrew Davis Wheeler Work Phone: 9196317572 Certificate Type: SI Certificate Grade: Select Certificate tt: 1006226 -------- Email Address:�eelerdagmail.com��^� Signature: LAEffective Date:_/ i// (t.1 a?— __,_ _ "I certify that I agree To my designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the rules and regulations pertaining to the responsibilities of the ORC as set forth In 15A NCAC 086 .0204 and falling to do so can result In Disciplinary Actions by the Water Pollution Control System Operators Certification Commission." _BACKUP ORC_ Print Full Name: Randall Jarrell Work phone:919-210-2500 �- Certificate Type: SI � Certificate Grade: Select Certificate # .23g25 _ Email Address: BiowaterQaol.com Signature: �- A." d Effective Date: i -I11 2.2. "I certify that i agree to my designation as a Back-up Operator In Responsible Charge for the facility noted. I understand and will abide by the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and foiling to do so can result In Disciplinary Actions by the Water Pollution Control System Operators Certification Commission." Mail, fax or email WPCSOCC,1618 Mail Service Center, Fax: 919.715-2726 Email: certadmin@ncdenr.gov ORIGINAL to: Raleigh, NC 27699-1618 Mail or Fax Asheville a COPY to: 2090 US Hwy 70 Swannanoa, NC 28778 Fax: 828-299-7043 Phone: 828-296-4S00 Fayetteville 225 Green St., Suite 714 Fayetteville, NC 28301-SO43 Fax: 910-486-0707 Phone: 910-433-3300 Mooresville Raleigh 610 E. Center Ave., Suite 301 3800 Barrett Dr. Mooresville, NC 2811S Raleigh, NC 27609 Fax:704-663-6040 Fax:919-571-4718 Phone:704-663-1699 Phone:919-791-4200 Washington Wilmington Winston-Salem 943 Washington Sq. Mail 127 Cardinal Dr. 45 W. Hanes Mail Rd. Washington, NC 27889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105 Fax:252.946-9215 Fax:910-350-2004 Fax:336-776-9797 Phone:252-946-6-481 Phone:910.796-7215 Phone:336-776-9800 Revisad4rnar6 f7 ^ 0 Division of Water Resources Non -Discharge Permitting Unit 1617 Mail Service Center Raleigh, North Carolina 27699-1617 DATE 11-30 "zL Subject: Signature Authority Designation To Whom It May Concern: As an appropriate signing official ford4i'V1 �( // • (city/lown/ county or business name) as designated by I SA NCAC 2T .0106, I hereby delegate authority to sign and certify all permit applications, reports or other permit related documents to the following staff for the following permit types (sewer, spray, land application) and/or permit numbers: Position Person Currently in Position Permit Type or Permit Number �► ms10ervb— G-1pg6 14,1 I.Aeek.r Ze- 0an0391-173 Op.r44••or") If you have any questions, please contact me at the following: Permittee/Applicant name (please print): GIP -AA {Zay Title: Pdes i d eel Y Complete mailing address: Mr` � � �Dx v City:�� Telephone number: M t!? 3 ( 71J.Y'r0 Sincerely, 6 signature State: O L Zip: X? 5 7(e Email tom