WQ0031874_Sewer Extension Permit Status Update_20190829

Request for Engineering Certification Date of Letter August 9,2019
Sewer Extension Permit Status Update
Please complete the applicable portion of this form for each permit and return to the Division by the delivery method below and
within 30 days of the date of this letter:
NCDEQ/DWR
WQPS—PERCS UNIT
By U.S.Postal Service: By Courier/Special Delivery: By Email: RECEIVED/NCDEQ/DWR
1617 Mail Service Center 512 N.Salisbury St.Suite 925 Nyle Hothem AUG 2 9
Raleigh,NC 27699-1617 Raleigh,NC 27604 [e-mail] 2019
Permit No.: IN Q 3 IS./if Permittee: •jr v►1Sw%c_. ^ 1 Permitting Section
Project Name: i ybve�S C v ei k T Q%/doTranobit £e 1e v
Project Status (Check appropriate box to indicate Permittee's response and complete&sign below)
Permit to Remain Open: The Permittee certifies that the permitted project has not been constructed but shall be constructed in
the future in conformity with the approved Permit,project plans,specifications,and supporting documents.The Permittee
understands that the appropriate certification documents will need to be forwarded to the Division prior to operation. Subject
permit shall be maintained in Active status.
❑ The Permitted project has been constructed and the required Engineer's Certification and supporting documents will be
submitted to the Division with this form. Permittee understands that failure to submit required certification documents for an
active,in-service system may result in enforcement action.
❑ Request Extension: Permittee requests extension to reply to
r to this letter not to exceed 60 days of the date of this letter.
Name&Title(print): w l(Z a w
t_ n 1— 'Pt h uyr�C i. t.., . '-,r o a"fC.x ins" 1•t-Car
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Signature: , 1 o-2"• Date: z2 Z J '9
Comments: -Ili c ✓o er± �� c,tL tle+ IC)esuin but wi tl
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Permit Rescission Request
The Permittee requests that the subject permit be rescinded and certifies that the permitted sewer system has not been and shall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:
Contact Information Updates •
Updated Contact Person: VIi l ►t &A L. el) KitA. P. C. b in-L'f'x r 14q
t J C}
Updated Mailing Address: P. d . R aX Z.L{ 1 Ea I:v t.ra. NC.- 2 ' L 2?—
Updated Email: tiV t I.I av"_1 st vt vt x @ 6 ru A✓

North Carolina Department of Environmental Quality
Division of Water Resources
Permit Number: W00031874 Version: 1.0 Issued Date: 8/10/2007
Permit Type: Gravity Sewer Extension,Pump Stations,&Pressure Sewer Extensions
Facility Name: Cypress Creek Development Sewer
Facility County: Brunswick Latitude: Longitude:
Facility Region: Wilmington
Owner Information Details:
Submit a Permit Ownership/Name Change form to DWR to make any changes to this Owner information.
Note that the owner is the legally responsible entity. (Click Here for PermitOwnership/Name Chancre"Form)
Owner Name: Brunswick County
Owner Affiliation: John Nichols Title: Utilities Director
Addressl: PO Box 249
Address2:
City,State&Zip: Bolivia,NC 28422-0249
Work Phone: [phone] Fax: [phone]
Email Address: John.Nicholse brunswickcountync.gov
Permit Engineer/Environmental Consultant
Name Organization Name Phone Email
Richard M Collier McKim&Creed 910-343-1048 [e-mail]
Permit Events
Event Description Date Comment
Permit issued 8/10/2007
Permit Comments(including all prior versions)
Date Comment Text Version
1.00
NOTE: Receipt of an Engineering Certification(Partial and/or Final)is required prior to operation of the facility.
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