NON-DOMESTIC WASTEWATER CONTRIBUTION PERMIT
APPLICATION
CITY OF CAYCE, SOUTH CAROINA
The undersigned being the ________________________________________
(Owner, Leasee, Tenant, Etc.)
of property located at ________________________________________
________________________________________
does hereby request a Wastewater Discharge Permit. The Permittee is
engaged in __________________________________________ business at the
said location.
The exact Name of the Permittee (Industry) that should appear on the
Wastewater Discharge Permit is:____________________________________
The mailing address is: ________________________________________
________________________________________
The following documents area required prior to issuing a Wastewater
Discharge Permit:
1.
A plan to the property showing accurately all sewers and
drains.
2.
Plan and specifications covering the work proposed to be
performed under this permit.
3.
A complete schedule of all process waters and industrial
wastes produced or expected to be produced at said
property, including a description of the character of
each waste, the daily volume and maximum rates of
discharge, representative analyses, and compliance with
any applicable Pretreatment Standard or Requirements. “I
understand that it is my responsibility to operate and
maintain the pretreatment facility, and to meet the Wastewater
Discharge Limits that will be issued in the Wastewater
Discharge Permit by the City of Cayce. I also understand that
I must obtain a Permit to Construct from SCDHEC prior to the
construction of pretreatment facilities and a Permit to
Operate from SCDHEC and the City of Cayce prior to the start-
up of pretreatment facilities, if applicable.”
“I certify under penalty of law that this document and all
attachments were prepared under my direction or supervision in
accordance with a system designed to assure that qualified
personnel properly gather and evaluate the information
submitted. Based on my inquiry of the persons who manage the
system, or those persons directly responsible for gathering
the information, the information submitted is, to the best of
my knowledge and belief, true, accurate, including the
possibility of fine and imprisonment for knowing violations.”
_________________________________________________________
Signature Printed Name Title Date
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