WQ0034814_Extension_20190621

y Sewer Extension Permit Status Update
W Permit No.: O 00 3�t 8 19 Permittee: Oct nse We kr and Se we P7G19-46`'%
Project Name: UNC MocehQ?id Vlane-ferliA /
For multiple permits with the same status,please attach a supplementary page indicating all permit numbers and project
names of the permits being addressed by this form.
Please complete the applicable remaining portion of this form and return to the Division at:
NCDEQ/DWR
WQPS—PERCS UNIT �t
y U.S.Postal Service: By Courier/Special Delivery: By Email: o.
130
1617 Mail Service Center 512 N.Salisbury St.Suite 925 Nyle Hothem o r�
Raleigh, NC 27699-1617 Raleigh, NC 27604 [e-mail]�
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Permit Shall Remain Open
We certify that the subject pt rrn;t( ) rn++;F+t'aen constructed but shall be constructed in the future in conformity with
the approved project plans,specifications,and supporting documents
OR that this project is currently under construction but is not yet in operation.
We understand that the appropriate certification documents must be forwarded to the Division prior to operation.
Please maintain the subject permit(s)in active status.
Name&Title(print): Ed e(R)in , Execs++ve Dif& 7Y( 1 Qrcnje �-f eretnc Sewer Aihari-/
Signature: 2 ,ate: v f tetbef
Comments: TFig R —1 1•-U AIO ;' e)E cJ2uo , CJ 3c �X5
e:51ED 1—kt ir P-Oudio 6 ,)
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Permit Rescission Request
We request that the subject permit(s)be rescinded and certify that the permitted sewer(s)have not been and shall not be
constructed nor made operational.We understand that,in the future,should we wish to operate a non-discharge sewer
system,we shall apply for and receive a new Wastewater Collection System Permit.
Name&Title(Print):
Signature: Date:
Comments:
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Contact Information Updates:
To update your contact information, including mailing address,please list that information below:
Updated Contact Person:
Updated Mailing Address:
Updated Email: