Fill and Sign the Rocky Mountain Elk Foundation State Grant Proposal Form Rmef

Standard Application Form for an Agricultural Permit for Stacking Sheds/Composters Please Type or Print Section 1 – FARM INFORMATION DATE OPERATION NUMBER ND NEW OR EXISTING IF EXISTING: PERMIT NUMBER OPERATION DATE ISSUED FARM NAME COUNTY LOCATION COMMUNITY APPLICATION FOR STACKING SHED COMPOSTER COMBINATION DOES THE STRUCTURE MEET NRCS SPECIFICATIONS? YES or NO ARE YOU APPLYING FOR EXCEPTIONAL QUALITY COMPOST QUALIFICATION? YESor NO IS THIS FACILITY ASSOCIATED WITH A MANURE BROKERING OPERATION? YES or NO DOES THIS OPERATION HAVE A TRAINED MANURE MANAGER? YES or NO TRAINING DATE Section 2 – CONTACT INFORMATION PERMIT APPLICANT ADDRESS PHONE NUMBER (WORK) (HOME) (CELL/BEEPER) ARE YOU THE PROPERTY OWNER OF RECORD? YES or NO IF NO, PROVIDE INFORMATION: PROPERTY OWNER OF RECORD ADDRESS PHONE NUMBER (WORK) (HOME) (CELL/BEEPER) OPERATOR’S NAME ADDRESS PHONE NUMBER (WORK) (HOME) (CELL/BEEPER) PLAN PREPARER TITLE/SC REGISTRATION NUMBER ADDRESS PHONE NUMBER (WORK) (FAX) (CELL/BEEPER) Section 3 – STORAGE/COMPOSTING FACILITY SEPERATION DISTANCES SEPARATION DISTANCES: MANURE STORAGE/COMPOSTING STRUCTURES Required Actual POTABLE WELLS 100 feet POTABLE WELLS OWNED BY THE APPLICANT 50 feet WATERS OF THE STATE LOCATED DOWNSLOPE (including ephemeral & intermittent streams) 100 feet* DITCHES OR SWALES LOCATED DOWNSLOPE 50 feet* PROPERTY LINE 200 feet** *distance may be reduced if a vegetative water quality buffer that meets NRCS guidelines is installed and maintained. DHEC 2512 (08/2002) SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL Section 4 – PERMIT APPLICATION SUBMITTAL REQUIREMENTS SUBMITTAL PACKAGE SHOULD INCLUDE 2 COPIES OF THE FOLLOWING ITEMS (check each item submitted): ____ 1. ORIGINAL APPLICATION (and 1 copy of the original) ____ 2. MANURE MANAGEMENT PLAN a. Animal Manure Management System Description b. Design Calculations and Construction Details for treatment/storage structure, including exact location and design information. c. Location maps (showing treatment/storage structure, and all fields) d. 100 year floodplain locations (treatment/storage structure may not be located in the 100-year floodplain) ____ 3. ODOR ABATEMENT PLAN ____ 4. VECTOR ABATEMENT PLAN ____ 5. WRITTEN CONSENT FOR WAIVING OR REDUCING SETBACKS FOR TREATMENT/STORAGE STRUCTURE (if applicable) Section 5 - CERTIFICATION I HEREBY CERTIFY THAT ALL OPERATIONS, MAINTENANCE AND ASSOCIATED ACTIVITY PERTAINING TO THIS SITE SHALL BE ACCOMPLISHED PURSUANT TO AND IN KEEPING WITH THE TERMS AND CONDITIONS OF THE APPROVED PLANS. I HAVE READ THIS APPLICATION AND AGREE TO THE REQUIREMENTS AND CONDITIONS THAT ARE CONTAINED WITHIN. THE INFORMATION SUBMITTED IS, TO THE BEST OF MY KNOWLEDGE AND BELIEF, TRUE, ACCURATE, AND COMPLETE. I HEREBY GRANT AUTHORIZATION TO THE DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL THE RIGHT OF ACCESS TO THE SITE AT ALL REASONABLE HOURS FOR THE PURPOSE OF SAMPLING AND ON SITE INSPECTIONS. Printed Name /Owner Signature/Owner I HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THAT THE DESIGN IS CONSISTENT WITH THE REQUIREMENTS OF TITLE 48, CHAPTER 1 OF THE 1987 SC CODE OF LAWS, AND PURSUANT REGULATION 61-43 AND APPROPRIATE NRCS STANDARDS. Printed Name/Plan Preparer DHEC 2512 (08/2002) Signature/Plan Preparer APPLICATION INSTRUCTIONS - Agricultural Permit for Stacking Sheds & Composters Purpose: This form must be completed as part of an application package submitted for DHEC approval of proposed NEW or EXPANDING agricultural manure stacking shed or composter. The required items should be checked to ensure that a complete administrative package has been submitted. If a complete administrative package is not submitted, the entire project may be returned. Item-by-Item Instructions: Section 1 - Contact Information. Date: Enter the date of application. Operation Number: Leave blank, Department will assign a facility number. New or Existing Facilities: If this application is for an existing operation that has previously obtained an agricultural permit from DHEC; indicate by circling EXISTING or NEW for new operations. If EXISTING, provide the following: Permit Number; Provide the permit number for the permitted operation, and Date Issued; Provide the date on which DHEC issued the permit. Farm Name: Give the name of the agricultural operation. County: Give the county in which the operation is located. Location: Give directions to the proposed operation from the nearest town or state road. Application Type: Indicate whether you are applying for a permit for a stacking shed, composter, or a combination or both a stacking shed and composter. NRCS Specifications: Circle YES or NO to indicate if the stacking shed and/or composter meets NRCS Specifications. Exceptional Quality Compost: Circle YES or NO to indicate whether you are applying for the manure treated at your facility to qualify as exceptional quality compost (must meet product quality standards outlined in Part 300 of R.61-43). Manure Brokering Operations: Circle YES or NO to indicate whether this application is being submitted for a stacking shed and/or composter that is associated with a manure brokering operation. Trained Manure Manager: Circle YES or NO to indicate whether the operator has attended the certified manure manager’s training and certification class conducted by Clemson Extension Service. Indicate the date on which the certification or training was obtained. Section 2 – Contact Information. Permit Applicant: Enter the name, address and phone numbers for the person who is applying for the permit. Property Owner of Record: Circle YES or NO to indicate whether the permit applicant is the property owner of record. Enter the name, address and phone number of the person who legally owns the property on which the proposed agricultural storage/ composting facility is to be located. Operator: Enter the name, address and phone number of the person who will be responsible for the daily operation of the proposed storage/composting facility. Plan Preparer: Enter the name of the plan preparer. Title/SC Registration Number: Enter the title and SC registration number (if applicable) of the person responsible for the design of the Animal Facility Management plan. Address, Phone Number: Enter the business address and phone numbers for the plan preparer. Section 3 – Storage/Composting Facility Separation Distances. Separation Distances: This table outlines the required setbacks for the manure storage and composting systems. Please enter the actual separation distance for the proposed storage/composting facility in the appropriate spaces. Section 4 – Permit Application Submittal Requirements. Please check each item that is being submitted as a part of this application. All items under Section 4 should be submitted to DHEC for review. Section 5 – Certification. For this section, please read the certification statements and have the appropriate person(s) sign the certification. DHEC Processing Procedures: Two (2) copies of the submittal package are submitted to DHEC. After Permitting, DHEC files the original in the main project file, located in DHEC’s central office. DHEC sends a copy of the approved package to the appropriate EQC Region Office. DHEC 2512 (08/2002)