NC0088854_Permit Issuance_20090923

NPDES DOCUHENT SCANNINO COVER SHEET
NPDES
Permit:
NC0088854
Pine Lakes — Well #2 WTP
Document
Type:
Permit Issuance
f
Wasteload Allocation
Authorization to Construct (AtC)
Permit Modification
Complete File - Historical
Engineering Alternatives (EAA)
Return
Instream Assessment (67b)
Speculative Limits
Environmental Assessment (EA)
Document Date:
September 23, 2009
This document is printed on reuse paper - ignore any
content on the rewrote side

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wipr
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Govemor Director Secretary
September 23, 2009
Mr. Thomas Roberts, President
Aqua North Carolina, Inc.
202 MacKenan Court
Cary, NC 27511
Subject: Issuance of NPDES Permit NC0088854
Pine Lakes Subdivision Well #2
Surry County
Dear Mr. Roberts:
Division personnel have reviewed and approved your application for a new NPDES discharge.
Accordingly, we are forwarding the attached NPDES discharge permit. This permit is issued pursuant to the
requirements of North Carolina General Statute 143-215.1 and the Memorandum of Agreement between North
Carolina and the U.S. Environmental Protection Agency dated October 15, 2007 (or as subsequently amended).
This final permit includes no major changes from the draft permit sent to you on July 14, 2009.
If any parts, measurement frequencies or sampling requirements contained in this•permit are unacceptable
to you, you have the right to an adjudicatory hearing upon written request within thirty (30) days following receipt
of this letter. This request must be in the form of a written petition, conforming to Chapter 150B of the North
Carolina General Statutes, and filed with the Office of Administrative Hearings (6714 Mail Service Center, Raleigh,
North Carolina 27699-6714). Unless such demand is made, this decision shall be final and binding.
Please note that this permit is not transferable except after notice to the Division. The Division may
require modification or revocation and reissuance of the permit. This permit does not affect the legal requirements
to obtain other permits which may be required by the Division of Water Quality or permits required by the
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
An Equal Opportunity 1 Affirmative Action Employer
•
Nose Carolina
�tura!!,

Division of Land Resources, the Coastal Area Management Act or any other Federal or Local governmental permit
that may be required. If you have any questions concerning this permit, please contact Sergei Chernikov at
telephone number [phone].
Sincerely,
(-4
Coleen H. Sullins
cc: Winston Salem Regional Office -Surface Water Protection
NPDES File
Central Files
Aquatic Toxicology Unit (e-copy)
J. Thurman. Horne P.E. (e-copy)
Horizon Engineering and Consutling, Inc.
2510 Walker Rd., Mt. Pleasant, N.C. 28124
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone] \ Customer Service:1.877-623-6748
Internet: www.ncwaterquality.org
An Equal opportunity 1 Affirmative Action Employer
Nne
orthCarohna
Naturally

Permit NC008885.4
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
PERMIT
TO DISCHARGE WASTEWATER UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1,
other lawful stand,rds and regulations promulgated and adopted by the North Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended,
Aqua North Carolina, Inc.
is hereby authorized to discharge wastewater from a facility located at the
Pine Lakes Subdivision — Well #2
Gloria Road
Mount Airy
Surry County
to receiving waters designated as an unnamed tributary to Stewart Creek in the Yadkin -Pee Dee River Basin
in accordance with effluent limitations, monitoring requirements, and other conditions set forth in Parts I,
II, III, and IV hereof.
This permit shall become effective October 1, 2009.
This permit and authorization to discharge shall expire at midnight on February 28, 2014.
Signed this day September 14, 2009
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission

Permit NC0088854
SUPPLEMENT TO PERMIT COVER SHEET
All previous NPDES Permits issued to this facility, whether for operation or discharge are hereby revoked. As of this
permit is suance, any previously issued permit bearing this number is no longer effective. Therefore, the exclusive
authority to operate and discharge from this facility arises under the permit conditions, requirements, terms, and
provisions included herein.
Aqua North Carolina, Inc. is hereby authorized to:
1. Continue to operate a water treatment plant with discharge of filter backwash wastewater. This facility
is located at the Pine Lakes Subdivision — Well #2, off Gloria Road near Mount Airy in Surry County.
2. Discharge from said treatment works at the location specified on the attached map into an unnamed
tributary to Stewarts Creek, a class WS-W water in the Yadkin -Pee Dee River Basin.

Permit NC0088854
A. (1) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS
During the period beginning upon the effective date of the permit and lasting until expiration, the Permittee
is authorized to discharge from outfall 001. Such discharges shall be limited and monitored by the
Permittee as specified below:
Parameter
Limits
Monitoring Requirements
Monthly
Average
Daily
Maximum
Measurement
Frequency
Sample
Type
Sample
Location
Flows
0.002 MGD
Monthly
Instantaneous
Effluent
Total Suspended
Solids
30.0 mg/L
45.0 mg/L
2/Month
Grab
Effluent
Total Residual Chlorine'
17 µg/L
2/Month
Grab
Effluent
Total Iron
Monthly
Grab
Effluent
Total Manganese
Monthly
Grab
Effluent
pH
> 6.0 and < 9.0 standard
—
units
2/Month
Grab
Effluent
Footnotes:
1. For instantaneous flow monitoring, the duration of the discharge must be reported in addition to the
total flow.
2. The facility shall report all effluent TRC values reported by a NC certified laboratory including field
certified. However, effluent values below 50 µg/L will be treated as zero for compliance purposes.
The Permittee shall collect all samples from a representative discharge event.
The Permittee shall discharge no floating solids or foam visible in other than trace amounts.

. Chernikov, Sergei
From: Spencer, Lee
Sent: Wednesday, September 23, 2009 10:33 AM
To: Chemikov, Sergei
Cc: Kaufman, Tammy; James McRight; Taylor, Tammy
Subject: RE: please evaluate new NPDES discharge
Sergei,
I concur with the issuance of this permit.
Thanks,
Lee
Lee G. Spencer, P.E.
Regional Engineer
Public Water Supply Section
NC DENR Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: Chernikov, Sergei
Sent: Wednesday, September 16, 2009 10:09 AM
To: Spencer, Lee
Subject: please evaluate new NPDES discharge
Lee,
Please evaluate the proposed permit and let me know if you have any concerns or objections.
Thank you!
Sergei
Sergei Chernikov, Ph.D.
Environmental Engineer II
NPDES-West
Phone: [phone], fax [phone]
1617 Mail Service Center
Raleigh, NC 27699-1617
Express mail: 512 North Salisbury St.
Raleigh, NC 27606
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
1

Winston-Salem Journal
Advertising Affidavit
Winston-Salem Journal
P.O Box 3159
Winston-Salem, NC 27102
NCDENR/DWQ/POINT SOURCE BRANCH
ATTN: DINA SPRINKLE
1617 MAIL SERVICE CENTER
RALEIGH, NC 27699-1617
Account Number
3376309
Date
July 17, 2009
Date Category
Description
Ad Size
Total Cost
07/17/2009
Legal Notices
PUBLIC NOTICE North Carolina Environment
2 x 54 L
374.61
PUBLIC NOTICE
North Carolina Environmental
Management Commisslon/NPDES Unit
1617 Mall Service Center
Raleigh, NC 27699-1617
Notice of Intent to Issue a
NPDES Wastewater Permit
The North Carolina Environmental Management
Commission proposes to issue a NPDES wastewater
discharge permit to the person(s) listed below.
Written comments regarding the proposed permit
will be accepted until 30 days after the publish date
of this notice. The Director of the NC Division of
Water Quality (DWQ) may hold a public hearing
should there be a significant degree of public in-
terest Please mail comments and/or Information
requests to DWQ at the above address. Interested
persons may visit the DWQ at 512 N. Salisbury
Street, Raleigh, NC to review information on file.
Additional information on NPDES permits and thls
notice may be found on our website: www.ncwater
quality.org, or by calling [phone].
Davidson Water, Inc. requested renewal of permit
NC0084425 for Its water treatment plant in David-
son County; this permitted discharge is treated fil-
ter backwash wastewater to an unnamed tributary
to the Yadkin River in the Yadkin -Pee Dee River
Basin.
The Norfolk Southern Railway Company has applied
for renewal of NPDES permit NC0029246 for the
Spencer Yard in Davidson County. This permitted
facility discharges treated industrial wastewater
to South Potts Creek In the Yadkin Pee -Dee River
Basin.
The Aqua North Carolina, Inc requested a new per-
mit NC0088854 for Pine Lakes Subdivision Well # 2
in Surry County; this facility discharge is treated
filter backwash to unnamed tributary to Stewarts
Creek, Yadkin River Basin.
The Town of YadklrrvBle requested renewal of per-
mit NC0079260 for the Yadkinvllle WTP In Yadkin
County. This permitted discharge Is treated filter -
backwash wastewater to South Deep Creek in the
Yadkin -Pee Dee River Basin.
WSJ: July 17, 2009
Media General Operations, Inc.
Publisher of the
Winston-Salem Journal
Forsyth County
Before the undersigned, a Notary Public of Forsyth County, North Carolina, duly
commissioned, qualified, and authorized by law to administer oaths, personally appeared
D.H. Stanfield, who by being duly sworn deposes and says: that he is Controller of the
Winston-Salem Journal, engaged in the publishing of a newspaper known as Winston-Salem
Journal, published, issued and entered as second class mail in the City of Winston-Salem, in
said County and State: that he is authorized to make this affidavit and sworn statement: that
the notice or other legal advertisement, a true copy of which is attached hereto, was
published in the Winston-Salem Journal on the following dates:
07/17/2009
and that the said newspaper in which such notice, paper document, or legal advertisement
was published was, at the time of each and every such publication, a newspaper meeting all
the requirements and qualifications of Section 1-597 of the General Statutes of North
Carolina and was a qualified newspaper within the meaning of Section 1-597 of the General
Statutes of North Carolina.
This 17th day of July, 2009
(signature of pers
Sworn to and subscribed before me, this 17th day of July, 20
My Commission expires
2J710
Not
ii
davit)
KIMALEY JOHNSON
NOTARY PUBLIC
FORSYTH COUNTY
STATE OF NORTH CARQLI
MY COMMISSION EXPIRES-1 LY•10/
THIS IS NOT A BILL. PLEASE PAY FROM INVOICE. THANK YOU

DENR/DWQ
FACT STET FOR NPDES PERMIT DEVELOPMENT
NPDES No. NC0088854
Facility Information
Applicant/Facility Name:
Aqua North Carolina, Inc/ Pine Lakes Subdivision — Well #2
Applicant Address:
202 MacKenan Court, Cary, NC 27511
Facility Address:
Gloria Road, Mt. Airy, NC 27030
Permitted Flow:
0.002 MGD
Type of Waste:
Water Treatment/Greensand filters
Other Permit(s):
N/A
Facility / Permit Status:
Class II/ New
County:
Surry County
Miscellaneous
Receiving Stream:
Stream Classification:
UT to Bull Creek
C WS-IV
Regional Office:
USGS Topo Quad:
Winston-Salem
B 16NE
303(d) Listed?
No
Permit Writer:
Sergei Chemikov
Subbasin:
03-07-03
Date:
July 8, 2009
Drainage Area (mi2):
Summer 7Q10 (cfs) :
N/A
0
Winter 7Q10 (cfs):
0
30Q2 (cfs) :
Average Flow (cfs):
IWC (%):
0
N/A
100
AARIP
Lat. 36° 30' 25" N Long. 80° 40' 55" W
BACKGROUND:
Pine Lakes Subdivision — Well #2 is a Class II, greensand water treatment plant will provide potable
water for a maximum of 73 customers in the residential subdivision. There are currently 4 greensand
filters, the filters are backwashed approximately once every 2 days. The backwash rate is 2,000 gallons.
Well #2 is approved for 16 gpm, which is sufficient to serve the subdivision. No expansion of the
subdivision or service area is planned. Effluent limitations are implemented based on the new Guidance
for Greensand Water Treatment Plants.
The Division has determined that the existing Water Treatment Plant is necessary to accommodate social
and economic growth in the area and that it will not result in contravention of surface water quality
standards or loss of designated uses in the receiving stream.
PROPOSED SCHEDULE FOR PERMIT ISSUANCE:
Draft Permit to Public Notice: July 14, 2009 (est.)
Permit Scheduled to Issue: September 7, 2009 (est.)
NPDES CONTACT:
If you have questions regarding any of the above information or on the attached permit, please contact
Sergei Chemikov at [phone].
REGIONAL OFFICE COMMENTS:
Name: Date:
Fact Sheet
NPDES NC0088854 Page I

cc: Central Files
WSRO
NPDES STAFF REPORT AND RECOMMENDATION
APPLICATION # NC0088854
To: Point Source Branch - SWP
Attention: Sergei Chernikov, Ph.D.
Date: July 14, 2009
County: Surry
PART I - GENERAL INFORMATION
1. Permittee Address: Aqua NC, Inc.
Pine Lakes Subdivision — Well #2 (Gloria Road, Mount Airy, NC)
4163 Sinclair Street
Denver, NC 28037
2. Date of Investigation: July 7, 2009
3. Report Prepared by: Gary Hudson, Environmental Specialist
4. Persons Contacted and Telephone Number: Billy Young, ORC, (336) — 755 — 4020
5. Directions to Site: Pine Lakes Subdivision is located off Gloria Road just west of North
Surry High School.
6. Discharge Points(s), List for all discharge points:
Latitude: 36° 30' 25" Longitude: 80° 40' 55"
U.S.G.S. Quad No. B-16-NE U.S.G.S. Quad Name Mount Airy, NC
7. Site size and expansion area consistent with application? Aqua owns a 100 ft. circle around
the well.
8. Topography: The well site is 30 yds off the road at the head of a small ravine.
9. Location of nearest dwelling: Several homes are located within 300 ft of the well.

10. Receiving stream or affected surface waters: U.T. to Stewarts Creek.
a. Classification: WS-IV
b. River Basin and Subbasin No.: YADO3
c. Describe receiving stream features and pertinent downstream uses: The filter
backwash will be discharged approximately 100 ft down slope of the well house
through a 4" pipe into the headwaters of a ravine that flows through the backyards of
several residents.
Part II - DESCRIPTION OF DISCHARGE AND TREATMENT WORKS
1. a. Volume of Wastewater to be permitted: The system is backwashed approximately
once every two days with an estimated flow of 2,000 GPD.
b. What is the permitted capacity of the well system? The Pine Lakes Well # 2 is
approved for 16 gpm (maximum yield) by the Public Water Supply Section and
serves 56 customers.
c. Actual treatment capacity of the current facility? See above.
d. Date(s) of AtC's issued in the previous two years. NA.
e. Please provide a description of existing or substantially constructed wastewater
treatment facilities: There is no treatment. The discharge is generated when the
green sand filters (4) are backwashed with potable water.
f. Please provide a description of proposed wastewater treatment facilities. N/A
g•
Possible toxic impacts to surface waters: The following chemicals are added:
Potassium Permanganate (for iron and manganese removal), chlorine
(for disinfection) and caustic soda (for pH adjustment).
h. Pretreatment Program (POTWs only): NA
2. Residuals handling and utilization/disposal scheme: None generated.
PART III - OTHER PERTINENT INFORMATION
1. Is this facility being constructed with Construction Grant Funds (municipals only)? NA.
2. Special monitoring or limitations (including toxicity) requests: NA.
3. Important SOC, JOC or Compliance Schedule dates: NA.
NPDES Permit Staff Report
Version 10/92
Page 2

4. Alternative Analysis Evaluation: No other disposal options available for this type of
operation.
PART IV - EVALUATION AND RECOMMENDATIONS
WSRO recommends issuance of the permit for the de minimis discharge created from
backwashing of the green sand filters at Well # 2 serving the Pine Lakes Subdivision.
f
Repo reparer & Date
WP Regional Supervisor & Date
NPDES Permit Staff Report
Version 10/92
/Vide-41-\ /3/479Loci
Page 3

Horizon Engineering & Consulting, Inc.
Ms. Susan Wilson
Supervisor, Western NPDES Program
Division of Water Quality
NPDES Unit
1617 Mail Service Center
Raleigh, N.C. 27699 - 1617
Subject: NPDES Permit Application
Proposed Well Backwash Discharge
Well No. 2
Aqua, North Carolina, Inc.
Pine Lakes Subdivision
Surry County
2510 Walker Road
Mt. Pleasant, N.C. 28124-8567
704-788-4455
Fax: [phone]
May 21, 2009
RECEIVED
J U N
DENR - WATER QUALITY
Dear Ms. Wilson: POINT SOURCE BRANCH
Attached are three (3) copies of the applications for NPDES permit signed by Aqua North
Carolina, Inc., three (3) copies of the Engineering Alternatives Analysis (EAA) and a check for
$ 860 (application fee.) This application is for a permit for the proposed discharge of backwash
from proposed green sand filters to be installed on an existing potable well which serves Pine
Lakes Subdivision, located outside Mount Airy, N.C. The EAA contains maps, which indicate
the existing location.
This is an existing groundwater well that has not yet been placed into service. Aqua North
Carolina, Inc. has filed an application with the Division of Public Water Supply to add the
proposed green sand filters and then distribute to the treated water to the Pine Lakes community.
The filters will be "backwashed" with water approximately once every two days and
approximately 2,000 gallons of water is then discharged into the nearby stream.
We appreciate your consideration of our application for permit. If you have any questions or if
there is anything we need to discuss, please call me (704-788-4455.)
C:
Tamara S. Taylor
Shashi Bhatta
Michael Melton
Dare Kimbrough
David G. Schlobohm
Scott Smart

NPDES PERMIT APPLICATION - SHORT FORM C - WTP
For discharges associated with water treatment plants
Mail the complete application to:
N. C. Department of Environment and Natural Resources
Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit Number
,Ncoo 18854.
If you are completing this form in computer use the TAB key or the up - down arrows to move from one
field to the next. To check the boxes, click your mouse on top of the box. Otherwise, please print or type.
1. Contact Information:
Owner Name
Facility Name
Mailing Address
City
Aqua North Carolina, Inc.
Pine Lakes Subdivision - Well # 2
202 MacKenan Court
Cary
State / Zip Code NC/27511
Telephone Number [phone]
Fax Number [phone]
e-mail Address [e-mail]
2. Location of facility producing discharge:
Check here if same as above
Street Address or State Road
City
State / Zip Code
County
Gloria Road
Mt. Airy
NC/27030
Surry
3. Operator Information:
Name of the firm, consultant or other entity that operates the facility. (Note that this is not referring to the
Operator in Responsible Charge or ORC)
Name
Mailing Address
City
State / Zip Code
Telephone Number
Fax Number
4. Ownership Status:
Aqua North Carolina, Inc.
202 MacKenan Court
Cary
NC/27511
[phone]
[phone]
Federal ❑ State ❑
5. Type of treatment plant:
Private ® Public ❑
Page 1 of 3
C-WTP 03/05

NPDES PERMIT APPLICATION - SHORT FORM C - WTP
For discharges associated with water treatment plants
❑ Conventional (Includes coagulation, flocculation, and sedimentation, usually followed by
filtration and disinfection)
❑ Ion Exchange (Sodium Cycle Cationic ion exchange)
® Green Sand Filter (No sodium recharge)
❑ Membrane Technology (RO, nanofiltration)
Check here if the treatment process also uses a water softener ❑
6. Description of source water(s) (i.e. groundwater, surface water)
Groundwater well
7. Describe the treatment process(es) for the raw water:
Green sand filtration using potassium permanganate. Chlorine added for disinfection.
Caustic soda added for pH adjustment.
8. Describe the wastewater and the treatment process(es) for wastewater generated by the
facility:
Wastewater discharge is the backwash of the green sand filters. Discharge rate is
approximately 2,000 gallons, once every two days.
9. Number of separate discharge points: 1
Outfall Identification number(s) 001
10. Frequency of discharge:
Continuous ❑ Intermittent
If intermittent:
Days per Week discharge occurs: 3 Duration: approx. 20 min.
11. Plant design potable flowrate 0.023 (Max. well yield) MGD
Backwash or reject flow 0.002 MGD
12. Name of receiving stream(s) (Provide a map showing the exact location of each outfall, including
latitude and Iongitude):
an unnamed tributary to Stewarts Creek (Yadkin River Basin)
13. Please list all water treatment additives, including cleaning chemicals, that have the
potential to be discharged.
Page 2 of 3
C-WTP 03/05

NPDES PERMIT APPLICATION - SHORT FORM C - WTP
For discharges associated with water treatment plants
potassium perafnanganate
chlorine
caustic soda
14. Is this facility located on Indian country? (check one)
Yes ❑ No
15. Additional! Information:
• Provide a schematic of flow through the facility, include flow volumes at all points in
the treatment process, and point of addition of chemicals.
• Solids Handling Plan
16. NEW Applicants
Information needed in addition to items 1-15:
• New applicants must contact the NCDENR Customer Service Center.
Was the Customer Service Center contacted? ® Yes ❑ No
• Analyses of source water collected
• Engineering Alternative Analysis
• Discharges from Ion Exchange and Reverse Osmosis plants shall be evaluated using a
water, quality model.
17. Applicant Certification
I certify that I am familiar with the information contained in the application and that to the
best of my knowledge and belief such information is true, complete, and accurate.
Tom Roberts
Printed n
L/ •\.`E) c)ZOCc
Si: ature of Applica - Date
North Carolina General Statute 143-215.6 (b)(2) provides that: Anyperson who knowingly () makes any Y false
statement representation, or certification in any application, record, report, plan, or other document files or
required to be maintained under Article 21 or regulations of the Environmental Management Commission
implementing that Article, or who falsifies, tampers with, or knowingly renders inaccurate any recording or
monitoring device' or method required to be operated or maintained under Article 21 or regulations of the
Environmental Management Commission implementing that Article, shall be guilty of a misdemeanor punishable
by a fine not to exceed $25,000, or by imprisonment not to exceed six months, or by both. (18 U.S.C. Section
1001 provides a punishment by a fine of not more than $25,000 or imprisonment not more than 5 years, or both,
for a similar offense.)
Page 3 of 3
C-WTP 03/05

Horizon Engineering & Consulting, Inc.
Mr. Dennis Thompson
County Manager
Surry County
118 Hamby Road
Dobson, NC 27017
Subject: Request for Local Government Review
NPDES Permit Application
Existing Well Backwash Discharge
Pine Lakes Subdivision
Surry County
Dear Mr. Thompson:
2510 Walker Road
Mt. Pleasant, N.C. 28124-8567
704-788-4455
Fax: [phone]
May 21, 2009
Attached is a copy of an application for permit signed by Aqua North Carolina, Inc. This
application is for a permit for the proposed discharge of backwash from filters to be installed on a
potable well which will serve the Pine Lakes Subdivision, located outside Mt. Airy off Highway
89. I have also attached a map to indicate the existing location.
As part of the application process, the state requires that we notify the local government and ask
that they complete the attached form which indicates whether the local government has a zoning
or subdivision ordinance and whether the proposed discharge is consistent with that ordinance.
This is a groundwater well that will filter water through a series of filters before the water is
distributed to the Pine Lakes community. The filters are "backwashed" with water approximately
once every two days and approximately 2,000 gallons of water is then discharged in to the nearby
stream.
We operate several similar systems in Surry County and we do not expect any environmental
concerns over this discharge, other than that the state requires that we must apply for a permit
and monitor the discharge in accordance with the permit.
We are trying to file this application as soon as possible. If you could complete, sign and return
this form, it will be very helpful.
We apologize for the necessity to ask for this assistance but I hope that you can appreciate our
dilemma. If you have any questions or if there is anything we need to discuss, please call me
(704-788-4455.)
C:
Dare Kimbrough
NC DENR

Local Government Review Requirements
for the Issuance of New Non -Municipal Domestic Wastewater Discharge Permits
General Statute Overview
North Carolina General Statute 143-215.1 (c)(6) allows input from local governments in the issuance of NPDES Permits for non -
municipal domestic wastewater treatment facilities. Specifically, the Environmental Management Commission (EMC) may not act
on an application for a new non -municipal domestic wastewater discharge facility until it has received a written statement from
each city and county government having jurisdiction over any part of the lands on which the proposed facility and its
appurtenances are to be located. The written statement shall document whether the city or county has a zoning or subdivision
ordinance in effect and'l(if such an ordinance is in effect) whether the proposed facility is consistent with the ordinance. The
EMC shall not approve a permit application for any facility which a city or county has determined to be inconsistent with zoning
or subdivision ordinances unless the approval of such application is determined to have statewide significance and is in the best
interest of the State.
instructions to the Applicant
Prior to submitting an application for a NPDES Permit for a proposed facility, the applicant shall request that both the
nearby city and county government complete this form.
The applicant must
• Submit a copy of the permit application (with•r..written request for this form to be completed) to the clerk of the
city and the county by certified mail, return receipt requested.
• If either (or both) local government(s) fail(s) to mail the completed form, as evidenced by the postmark on the
certified mail card(s), within 15 days after receiving and signing for the certified mail, the applicant may submit the
application to the NPDES Unit.
• As evidence to the Commission that the local government(s) failed to respond within 15 days, the applicant shall
submit a copy of the certified mail card along with a notarized letter stating that the local governments) failed to
respond within the 15-day period.
Instructions to the Local Government
The nearby city and/or county government which may have or has jurisdiction over any part of the land on which the
proposed facility or its appurtenances are to be located is required to complete and return this form to the applicant
within 15 days of receipt. The form must be signed and notarized.
Name of local government
S.Aff‘i 1 (City/County)
Does the city cou ' have ' sdiction over any part of the land on which the proposed facility and its appurtenances
are to be locate • Yes [ No [ ] If no, please sign this form, have it notarized, and return it to the applicant.
Does the city • unty ave in effect a zoning or subdivision ordinance? Yes ] No [ ]
If there is a zoningo division ordinance in effect, is the plan for the proposed facility consistent with the
ordinance? Yes No [ ]
Date i - Os-- O' Signature
State of pid ✓(?crTD1/,i4Coun of C$Lz✓r � y
On this �.' day of n e ,09111 1, personally appeared before me, the said
name.. b it it Zs . .Sl) to me known and known to me to be the person
e vn� h
described in and who executed the foregoing document and he (or she) acknowledged that he (or she)
executed the same and being duly sworn by me, made oath that the statements in the foregoing document
are true: .
My`Comm ssion expires .leC • .(Signature of Notary Public
Notary Public (Official Seal)