WQ0033360_Sewer Extension Permit Status Update_20190923

Request for Engineering Certification Date of Letter: September 6,2019
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: n C 1
NCDEQ/DWR RECEIVED
WQPS—PERCS UNIT
SEP 2 3 2019
By U.S. Postal Service: By Courier/Special Delivery: By Email:
1617 Mail Service Center 512 N.Salisbury St.Suite 925 Nyle Hothem NCDEQ/DWR/NPDES
Raleigh, NC 27699-1617 Raleigh, NC 27604 [e-mail]
Permit No.: Oa cv333 EGG Permittee: 74Jr o Ad c,
Project Name: CovA\-ry Club CceK 5C ta3c I 1SSueo( 8/ // o?
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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: this lettert� not to exceed 60 days of the date of this letter.
Name&Title(print);'-Th. ;[� Sa�►e5 44)er�n na(Clit- (fit- um-ec/yeu,P(-
Signature: I Date: 9/07
Comments: jec+ _Q_S �l1 f oYl hSc• kicy- _S J U5�' 5 i4o ban
4- s qer�
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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The Permittee requests that the subject permit be rescinded and certifies that the permitted sewer system has not been and shall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:
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Contact Information Updates
Updated Contact Person:
Updated Mailing Address:
Updated Email: