WQ0044512_Application (FTSE)_20230612

Robert, enclosed are the permit application and the check to renew our pump and
haul permit.
We are making progress on getting a new small system that will support us for
several years and plans to.add to the system as we grow.
Thank you for all your help during this time.
t-
Ed Kiley
Riversound POA
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I. PRESUBM17TAL INFORMATION:
1. Contacted representative from regional office (Pre -submittal)?: ® Yes ❑ No
2. Contact name (For Regional Office): Robert Tankard
II. APPLICANT INFORMATION:
1. Applicant's name (Municipality, Individual, Corporation, etc):
2. Applicant type: ❑ Municipal ❑ State ❑ Privately -Owned Public Utility
❑ County ® Other: Privately Owned
3. Origin of Wastewater.
® Residential Subdivision ❑ Retail (Stores, Shopping Centers)
❑ Apartments/Condominiums ❑ Institution
❑ Mobile Home Park ❑ Hospital
❑ School ❑ Church
❑ Restaurant ❑ Nursing Home
❑ Office ❑ Other (specify)
4. Signature authority's name: Edward Kiley per 15A NCAC 02T .0106(b)
Title: MA Vice President
5. Applicant's mailing address: PO Box 572
City: Edenton State: NC Zip: 27932-
6. Applicant's contact information:
Phone number. (91D 280-8664 Email:
III. CONTACT/CONSULTANT INFORMATION:
1. Contact name:
Title/Affiliation:
2. Contact's information:
Phone number. (___) _- Email:
Domestic: 100 %
Commercial: %
Industrial: %
Other. %
IV. RECEMNG 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 P. Sanchez
Title/Affiliation: Public Works Director
6. WWTF contact information:
Phone number: 252 426-3039
Email: pi blicworks(a�townofhertfordnc.com
APPLICATION P&H 01-16 Page 3 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?
❑ 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: ❑ 15A NCAC 02T .0114 or ® Representative Data
If representative data, describe: Current hauling per month
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 IGley , 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 n up to $2 per violation.
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Signinl-Cffldai Signature Date
ENGINEERING DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL
ACTIVITIES SHALL BE INSPECTED AT LEAST DAILY BY THE PERMITTEE OR ITS REPRESENTATIVE PER 15A NCAC 02T .0204(d).
APPLICATION P&H 01-16 Page 4 of 5