Updated_WLA000257request_Feb2024.pdf

Wastewater Regulatory Program New Facility

SECTION I. PERMIT TYPE

Please check the applicable box

Domestic/Municipal Wastewater Industrial Wastewater

Individual Permit Individual Permit

2A – Municipal Wastewater Discharge Application 2B – Concentrated Animal Feeding Operation and Aquatic Animal Production

2E – Non-Process Wastewater (Sanitary Wastewater) 2C – Industrial Wastewater Discharge Application

Domestic/Municipal Land Application System Permit 2D – New Sources & New Dischargers

Industrial Pretreatment Permit

Industrial Land Application System Permit

General Permit General Permit

Land Application System GP for Large Community Systems (Permit No. GAG278000)

NPDES GP for Settlement Pond Discharge from Sand & Gravel Dredgers (Permit No. GAG100000)

NPDES GP for Private and Institutional Development Water Pollution Control Plant Activities (Permit No. GAG550000)

NPDES GP for Once-Through Non-Contact Cooling Water with No Additives (Permit No.

GAG200000)

NPDES GP for Reclaimed Water Discharges Associated with the City of Pooler, Georgia (Permit No. No. GAG600000)

NPDES GP for Mining and Processing Facilities (Permit No. GAG300000)

Land Application System GP for Land Disposal of Domestic Septage (Permit No. GAG620000)

CAFO General Permit for LAS Medium: 301-1000 AU (Permit No. GAG920000)

NPDES GP for Drinking Water Treatment Plant Filter Backwash (Permit No. GAG640000)

CAFO General Permit for Individual Discharge (Permit No. GAG930000)

NPDES GP for Discharges of Pesticide Applications to Waters of the State (Permit No.

GAG820000)

CAFO General Permit for LAS: Large >1000 AU (Permit No. GAG940000)

Underground Injection Control

Underground Injection Control Class V Injection Well Permit Application with Checklist

Underground Injection Control Class V Mixed Waste Nondomestic Septic System

For EPD Use Only Permit No.______________________

SECTION II. APPLICANT & FACILITY INFORMATION

Applicant Organization/Legal Name:

Applicant Mailing Address:

City: State: Zip Code: County:

Facility Name:

Facility Address:

City: State: GA Zip Code: County:

Facility Site Coordinates. Centroid of the facility. (ex. 34.545263, -84.885404):

If there are any other wastewaters permits associated with this facility provide the corresponding permit no.

and check the applicable box(s).

Associated Permit No.:

Associated Permit No. Reason (check applicable box)

Switched to an individual permit Effluent Trade Partner (ETP) Other Switched from a Land Treatment System Switched To A General Permit (SGP)

SIC Code(s) (4-digit in order of priority):

1st: 2nd: 3rd: 4th

NAICS Code (s):

1st: 2nd: 3rd: 4th

SECTION III. CONTACT INFORMATION

Contact Affiliation Type:

Owner Contact Contractor Permit Contact Engineer Project Contact Unknown

First Name Last Name: Title:

E-mail Address: Phone No.:

SECTION IV. LIST ADDITIONAL PERMITS ISSUED BY EPD

1. Provide the name and permit nos. for all permits issued to this facility

Name of Permit Permit No.

SECTION V. NATURE OF BUSINESS

1. Describe the nature of your business:

5. Describe the wastewater treatment process (if known):

6. Additional Information (history, special conditions, etc.):