WQ0040465_Application_20181121

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I. PRESUBMITTAL INFORMATION: `-' D
1. Contacted representative from regional office (Pre -submittal)?: ® Yes ❑ No
2. Contact name (For Regional Office): Jason Robinson
It. APPLICANT INFORMATION:
1. Applicant's name (Municipality,
Individual, Corporation, etc): Moffat Pipe, Inc.
2. Applicant type: ❑ Municipal
❑ State ❑ Privately -Owned Public Utility
❑ County
® Other: Contractor
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: Jesse Duclau per 15A NCAC 02T .0106 b
Title: Proiect Manager
S. Applicant's mailing address: 4901 Unicon Dr
Domestic: 100 %
Commercial: %
Industrial: %
Other: %
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City: Wake Forest State: NC Zip: 27587-� 0 0
6. Applicant's contact information: i R
tia Z 0,
Phone number: [phone] Email: [e-mail]
Ill. CONTACT/CONSULTANT INFORMATION:rjQ
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1. Contact name: Krista Paredes -Toledo
Title/Affiliation: Water/Wastewater Engineer, AECOM 0
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2. Contact's information:
Phone number: [phone] Email: krista. aredes(@aecom.com+ (� Sir _r0"Yf�
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: Orange Water and Sewer Authority
2. Facility name: Mason Farm Wastewater Treatment Plant
3. Facility permit number: NCO025241
4. WWTF permit number: W 0001169 W 0021828 W 0031506
S. WWTF contact name: Monica Dodson
Title/Affiliation: Wastewater Treatment and Biosolids Recycling Manager
6. WWTF contact information:
Phone number: [phone] Email: mdodsonagwasa.arg
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APPLICATION P&H 01-16 Paue 3 of 5

V. PROJECT INFORMATION:
1. Location of Project (physical address): 7619 Rogers Rd. Chapel Hill, NC 27516
Approximate Coordinates (Decimal Degrees): latitude: 35.9634210 Longitude:-79.088392o
2. Duration of Pump and Haul Request (Six Months Typical): 3 months
3. Has a prior permit been issued? ® New ❑ Prior Pump & Haul Permit
Permit No.:
4. Permanent Method of Wastewater Disposal: Gravily Sanitary Sewer System
5. Date Permanent Disposal will be available: March 2019
6. Have permits / approvals for permanent disposal been obtained?
® Yes ❑ No Permit Number: W000038937
7. Is there a Pretreatment Program in effect? ❑ Yes ® No
8. Describe any pretreatment prior to pumping and hauling:
9. Volume of Wastewater Generated: 240 Gallons per Day
10. Explain how the wastewater flow was determined: ® 15A NCAC 02T .0114 or ❑ Representative Data
If representative data, describe:
11. Describe Tank / Container wastewater will be pumped from (attach description if necessary): x
4' diameter, by 7' high precast concrete manhole �-- �'' f r 4
12. Is Tank / Container in place or will it be installed (attach description if necessary):
In place
13. What type of high water alarm does the container have (and/or):
® Audible and Visual ® Telemetry (Auto Dialer / SCADA)
VI. CERTIFICATION:
Applicant's Certification: (Signature of Signing Official and Project Name)
attest that this application for Widko&kI PUP19 L. 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
up to 25,000 per violation.
aA, 11 Zb Ulf
Signin 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 Pave 4 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.
2. Professional Engineer's Certification: (Signature of Design Engineer and Project Name)
I, Krista Paredes -Toledo ,attest that this application for Rogers Road Emergency Pump and Haul 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
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. Krista Paredes -Toledo
Professional Engineer Name
2b. AECOM Techni
Engineering Firm
2c. 1600 Perimeter Park Drive, Suite 400
Mailing Address
2d. Morrisville 2e. NC 2L 27560
City State Zip
'2g. 919-461-1564
Telephone
2h. 919-461-1415 2i. [e-mail]
Facsimile E-mail
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APPLICATION P&H 01-16 Paee 5 of 5

haul activities nee Joel Lloyd _ Se
needed for the request Service "Hauler" is Capable
and willing to � COmpanY Name: Joe! Lloyd The Hauler" co perform the pump and
Owner: Joel Lloyd Yd ` Septic S mpany information is ' Location: Cha Service as follows:
' Email: gel Ni!!, NC 27516 [e-mail]
Mobile: [phone]
' Permit NCS; #01207
' Hauling Volume;
2,500 gallon
If You have any questions or concerns, please do not hesitate
Regards to contact directly.
Joel
JOEL LLOYD—SEPTIC SERVICE

ORANGE WATER AND SEWER AUTHORITY
rl public, non profit agency providing water, sewer and reclaimed water services
to the Carrboro-Chapel Hill community.
TO: Moffat Pipe Inc. & DWR (Jason Robinson)
FROM: Wilmer Lawson (OWASA Operation Supervisor/ORC)
DATE: 11/20/2018
SUBJECT: Pump and Haul Acceptance
The OWASA Mason Farm Wastewater PIant will accept up to 300 gallons per day of
domestic wastewater related to the Rogers rd. project per our typical tipping fee and
standard procedures,
ilmer Lawson
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Operations Supervisor/ORC
OWASA Mason Farm WWTp
lac- Dept OF Environmental Quality
NOV 21 2M
Ueigh Regional Office
400 Jones Ferry Road Equal Opportunity Employer Voice (919) 968-4.421
Carrboro, NC 27510- 2001 Printed an Recycled Paper
www.owasa, orb

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ORANGE WATER AND SEWER AUTHORITY
A public, non-profit agency providing water, sewer and reclaimed water services
to the Carrboro-Chapel Hill community.
TO: Moffat Pipe Inc. & DWR (Jason Robinson)
FROM: Wilmer Lawson (OWASA Operation Supervisor/ORC)
DATE: 11/20/2018
SUBJECT: Pump and Haul Acceptance
The OWASA Mason Farm Wastewater Plant will accept up to 300 gallons per day of
domestic wastewater related to the Rogers rd. project per our typical tipping fee and
standard procedures.
Wilmer Lawson
Operations Supervisor/ORC
OWASA Mason Farm WWTP
400 Jones Ferry Road Equal Opportunity Employer Voice [phone]
Carrboro, NC 27510-2001 Printed on Recycled Paper wwn.owow.org