HomeMy WebLinkAboutWQ0000265_Information Received_20210810August 4, 2021
Division of Water Resources
Non -Discharge Branch
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
To Whom It May Concern:.
Subject: Permit No. WQ0000265
Signature Authority Designation
Washington Correctional Center
Wastewater Irrigation System
Washington County
As an appropriate signing official for North Carolina Department of Transportation (city/town or
business name) as designated by 15A NCAC 2T .0106, I hereby delegate authority to sign and certify all
permit applications, reports or other permit related documents to the following staff for the following
permit types (sewer, spray, land application) and/or permit numbers:
Position
Person
Currently in
Position
Permit Type
or Permit
Number
David Heath Stallings
Facilities Maintenance Engineer
WO0000265
Steve Trowell
Environmental Specialist II
WO0000265
If you have any questions, please contact me at the following:
Permittee/Applicant name (please print): North Carolina Department of Transportation C/O Ronnie L. Keeter Jr., PE
Title: Chief Engineer
Complete mailing address: 1536 Mail Service Center
City: Raleigh State: NC Zip: 27699-1536
Telephone number: ( 919 ) 707-2500 Facsimile number:( 919 ) 733-9428
Since l• IY,
si;aature
DocuSign Envelope ID: C64F1ED7-1419-4E5A-A7A9-A2075E3CE0AB
State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE PERMIT OWNERSHIP/NAME CHANGE
Division of Water Resources INSTRUCTIONS FOR FORM: NDPONC 06-16 & SUPPORTING DOCUMENTATION
This form is for ownership changes or name changes of a non -discharge system permit. Please note that "Permittee"
references the existing permit holder, and that "Applicant" references the entity applying for the ownership/name change.
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit website
A. Non -Discharge Permit Ownership/Name Change (FORM: NDPONC 06-16) Application (All Applications):
0 Submit an original completed and appropriately executed Non -Discharge Permit Ownership/Name Change (FORM: NDPONC
06-16) application.
❑ The Existing Permittee's Certification shall be signed in accordance with 15A NCAC 02T ,0106(b). Per 15A NCAC 02T
.0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from a person who
meets the criteria in 15A NCAC 02T .0106(bl.
❑ The Applicant's Certification shall be signed in accordance with 15A NCAC 02T .0106(b). Per 15A NCAC 02T .0106(c). an
alternate person may be designated as the signing official if a delegation letter is provided from a person who meets the criteria
in 15A NCAC 02T .0106(l ).
B. Existing Permit (All Applications):
0 Submit a copy of the most recently issued permit.
C. Property Ownership Documentation (All Applications):
➢ Per 15A_ NCAC: 02T .0504(1). 15A_ NCAC 02T .0604(e), 15A NCAC 02T .0704(f), 15A NCAC 02T .0804, 15A NCAC 02T
.10�d) 15A NCAC 02T .1104(d)(7), 15A NCAC 02T .l 104 e 5 , 15A NCAC 02U .0201(e) or 15A NCAC 02U,.0202().
the Applicant shall demonstrate they are the owner of all property containing the non -discharge system facilities:
El Legal documentation of ownership (i.e., GIS, deed or article of incorporation), or
❑ Written notarized intent to purchase agreement signed by both parties with a plat or survey map, or
❑ Written notarized lease agreement that specifically indicates the intended use of the property and has been signed by both
parties, as well as a plat or survey map. Lease agreements shall adhere to the requirements of 15A NCAC 02L .0107.
D. Certificate of Public Convenience and Necessity (All Applications where the Applicant is a Privately -Owned Public Utility):
❑ Per I SA NCAC 02T .0115(a)(1 ], provide one copy of the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served
by the non -discharge system.
E. Operational Agreements (All Applications where the Applicant is a Home/Property Owners' Association or Developer of lots to
be sold):
➢ Hotne/Property Owners' Associations
0 Per 15A NCAC 02T .0115 c , submit an original properly executed Operational Agreement FORM: 110A .
❑ Per 15A NCAC 02T .01 15c , submit an original proposed or approved Articles of Incorporation, Declarations and By-
laws.
➢ Developm of lots to be said
❑ Per 15A NCAC 02T .0115 , submit an original of the properly executed Operational Agreement (FORM: DEV).
F. Operation and Maintenance Agreement (All Applications for Single -Family Wastewater Irrigation Systems):
❑ Per 15A NCAC 02T .0604(h], submit an original of a notarized Operation and Maintenance Agreement FORM: SFRW WIS
O&M that has been signed and dated by all deeded property owners.
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED TO:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DMSION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE PERMITTING UNIT
By U.S. Postal Service: By Courier/Special. Delivery:
Non -Discharge Branch Non -Discharge Branch — Archdale 942W By Email:
1617 Mail Service Center 512 N. Salisbury St. Non-Discharge.Reppris _ ncdennoy
Raleigh, NC 27699-1617 Raleigh, NC 27604
Telephone Number: (919) 707-3654
INSTRUCTIONS FOR FORM: NDPONC 06-16 & SUPPORTING DOCUMENTATION Page 1 of 1
DocuSign Envelope ID: C64F1 ED7-1419-4E5A-A7A9-A2075E3CE0AB
Division of Water Resources
I. EXISTING PERMITTEE INFORMATION:
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE PERMIT OWNERSHIP/NAME CHANGE
FORM: NDPONC 06-16
I. Permittee's name: North Carolina Department of Public Safety
2. Signature authority's name: Jeffrey T O'BrianL PE per 15A NCAC 02T .0106 Title: nirocwr�tj.n�in�rring
3. Permittee's mailing address: 4216 MailService, Center
City: Raleigh State: NC Zip: 27699 - 3400
4. Permittee's contact information: Phone number: (1W 716 - 3400 Email Address: jgffny obriantQncdns.gov
5. Demonstration of historical consideration for permit approval — 15A NCAC 02T .0120:
Has the Permittee or any parent, subsidiary or other affiliate exhibited the following?
a. Has been convicted of environmental crimes under Federal law or G.S. 143-215.6B? ❑ Yes or ❑✓ No
b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or ❑✓ No
c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes or ✓❑ No
d. Is non -compliant with an existing non -discharge permit, settlement agreement or order? ❑ Yes or ❑✓ No
e. Has unpaid annual fees in accordance with 15A NCAC 02T .0105(c)(2)7 ❑ Yes or ❑✓ No
II. FACILITY INFORMATION:
1
2
Facilityname:
Facility's physical address: 13842LNE H= 24_
City: Creswell State: -C Zip: 27928 -
III. PERMIT INFORMATION:
County: Washington
1. Existing permit number: WQ00 00265 and most recent issuance date: 5/20/2019
2. Existing permit type: Wastewater Irrigation
3. Reason for the permit application: Change of Ownership
4. Has the facility been constructed? ❑✓ Yes or ❑ No
IV. APPLICANT INFORMATION:
1. Applicant's name: North Cam1jna EL- rtment of Transsortation
2. Signature authority's name: Stgr i g D Bakm PE,,,Steve Trnwpll per 15A NCAC 02T .0I06(h) Title: Division_ Engineer
3. Applicant's mailing address: 113 AjlpOrt IMMe, ui#e100Environmental Specialist II
City: Edenton State: NC Zip: 2 2-
4. Applicant's contact information: Phone number: (2 2 482 - 1850 Email Address:
5. Demonstration of historical consideration for permit approval —15A NCAC 02T .0120:
Has the Applicant or any parent, subsidiary or other affiliate exhibited the following?
a. Has been convicted of environmental crimes under Federal law or G.S. 143-215.6B? ❑ Yes or ❑✓ No
b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or ❑✓ No
c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes or ❑✓ No
d. Is non -compliant with an existing non -discharge permit, settlement agreement or order? ❑ Yes or ❑✓ No
e. Has unpaid annual fees in accordance with 15A NCAC 02T .0105fe)f21? ❑ Yes or ❑✓ No
FORM: NDPONC 06-16 Page 1 of 2
DocuSign Envelope ID: C64F1 ED7-1419-4E5A-A7A9-A2075E3CEOAB
Existing Permittee's Certification per 15A NCAC 02T .0106(b):
1, Jeffrey T O'Briant, Interim Director of Engineering _ attest that this application for
(Signature Authority's name & title from Application Item I.2.)
Washington Correctional Center WWTF
(Facility name from Application Item H.1.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that prior to reissuance of the permit
into the Applicant's name, any discharge of wastewater from this non -discharge system to surface waters or the land will result in an
enforcement action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the
Division of Water Resources should a condition of the existing permit be violated. I also understand that if all required parts of this
application package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned as incomplete. I further certify that the existing Permittee or any affiliate has not been convicted of an
environmental crime, has not abandoned a wastewater facility without proper closure, does not have an outstanding civil penalty where
all appeals have been exhausted or abandoned, are compliant with any active compliance schedule, and do not have any overdue annual
fees per 1.5A NCAC 02T .0105(e).
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature: Date: 6/16/2021 1 16:41:36 EDT
Applicant's Certification per 15A NCAC 02T ,o1Q6(h):
1, Sterling D Baker, NC Department of Transportation, Division 1 Engineer attest that this application for
(Signature Authority's name & title from Application Item IV.2.)
Washington Correctional Center WWTF
(Facility name from Application Item II.1.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that after reissuance of the permit
into the Applicant's name, any discharge of wastewater from this non -discharge system to surface waters or the land will result in an
enforcement action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the
Division of Water Resources should a condition of this permit be violated. I also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application package
will be returned to me as incomplete. I further certify that the Applicant or any affiliate has not been convicted of an environmental
crime, has not abandoned a wastewater facility without proper closure, does not have an outstanding civil penalty where all appeals have
been exhausted or abandoned, are compliant with any active compliance schedule, and do not have any overdue annual fees per 15A
NCAC 02T .0105(e).
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as well as civil penalties up to $25,000 per violation.
f- (b - 6/16/2021
Signature: Date: _
CA 03 7A842
FORM: NDPONC 06-16 Page 2 of 2
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Attribute
Value
NCPIN
7759181395
TAX PIN
7759.00-18-1395
Featld
5969
OwnerAddl
116 W JONES ST
OwnerAdd2
c/o STATE PROPERTY OFFICE
STATE
NC
CITY
RALEIGH
ZIP
27603
DB PG
323/112
DeedDate
1989 SEP 28
OWNER s
STATE OF NORTH CAROLINA
AreaAC
27.357
PropLoc
BEHIND 13842 NC HWY 94 N
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Attribute
Value
NCPIN
7759097272
TAX PIN
7759.00-09-7272
Featld
5968
OwnerAddl
116 W JONES ST
OwnerAdd2
c/o STATE PROPERTY OFFICE
STATE
NC
CITY
RALEIGH
ZIP
27603
DB PG
323/112
DeedDate
1989 SEP 28
OWNER s
STATE OF NORTH CAROLINA
AreaAC
30.661
PropLoc
BEHIND 13842 NC HWY 94 N