NCS000559_Renewal Application_20220822

MAYOR MAYOR PRO TEM
Jody L.McLeod Jason llcmnpson
EVTERIM TOWN MANAGER COUNCIL MEMBERS
Richard D.Cappola,Jr. Andria Arclicr
TOWN ATTORNEY o4 Porter Casey
Avery Evcrett
Cauley Pridgen, P.A. Michael Sims
3 August 2022
DEQ-DEMLR Stormwater Program
Attn: MS4 Permitting
1612 Mail Service Center
Raleigh, NC 27699-1612
Re:Town of Clayton NPDES MS4 Permit Application (NCS000559)
To Whom it May Concern:
The Town oh Clayton (Town) is pleased to submit the NPDES MS4 Pen nit Application for die
upcoming MS4 permit cycle. As a permitted MS4 entity in North Carolina, the Town is required
to submit a penuit renewal application no later than 180 clays prior to the expiration of the current
NPDES MS4 permit which is set to expire on January 31, 2023.
Please Lind die Town's NPDES MS4 Permit Application with original signature enclosed in this
packet. Additionally, the draft Stornnwater Management Plan (SWMP) is also enclosed for review
and consideration.
An audit of the Town's MS4 prograin was perfornied by NCDEQ staff on March 30, 2022. While
die Town has completed a comprehensive update to the enclosed drafl SWMP, die findings
report of the recently performed audit have yet to be received by die Town. Upon receipt of the
audit findings report, the SWMP will be updated, as necessary, to ensure compliance with the
NPDES MS4 prograu.
If NCDEQ/DEMI.R staff have any questions or concerns related to the enclosed pernil
application or draft SWMP, please do not hesitate to let me know.
Sincerely,
Joshua B. Baird, PE, CFM ���
Engineering Director
Town of Clayton Engineering 2 2
LAND QUALITY SEcnON ASHEVlLLE
Think
PO Box 879 • Clayton,NC 27528 • 919,553-5002 CLWbi_�� Fax [phone] • ClaytonNC,org • Page 1 of 1

NPDES MS4 Permit Application Form
National Pollutant Discharge Elimination System (NPDES)
m+ �^' Municipal Separate Storm Sewer System (MS4)
Please complete the information below and submit this form along with the required supplemental information
to the address indicated.
Part I: Permittee Information
Current Permit No. NCS 000559
MS4 Name Town of Clayton
Owner Name* Richard D. Cappola
Owner Title Interim Town Manager tzlvcLj
Street Address 111 E. Second Street Aus7 08 2092
City, State Zip Clayton, NC 27520 pE ,
Phone Number 919-553-5002 STGRMWATERja
E-mail Address [e-mail]
* The owner must be a principal executive officer or ranking elected official for the city/town/entity that
owns/operates the permitted MS4. Any permit enforcement actions will be sent to the owner on record.
Part II: Primary Contact**
Contact Name Joshua Baird, PE, CFM
Contact Title Engineering Director
Employer Town of Clayton
Street Address 111 E. Second Street
City, State Zip Clayton, NC 27520
Phone Number 919-553-5002
E-mail Address I [e-mail]
**The primary contact is the responsible party who will oversee the day-to-day permit compliance and
Stormwater Management Program implementation. With the exception of enforcement actions,permit
communications originating from NCDEQ will be sent to the primary contact and will be copied to the other
contacts listed below.
Part III: Other Contacts
Contact Name Jonathan Jacobs, PE, CFM
E-mail Address [e-mail]
Contact Name
E-mail Address
Part IV: Required Supplemental Information
Submit one (1) hard copy and one (1) electronic copy of a Draft Stormwater Management Plan (SWMP)
with this permit application. The Draft SWMP must be in the current NCDEQ SWMP Template format
and shall include all required information in order for the permit renewal application to be considered
complete. RECEIVED
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Part V: Certification
By my signature below I hereby 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 person or 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, and
complete.
I am aware that there are significant penalties for submitting false information, including the possibility
of fines and imprisonment for knowing violations. I am also aware that incomplete permit renewal
applications, inclusive of the required Draft SWMP, will not be processed and will be returned to the
permittee.
❑ I am a ranking elected official for the permitted MS4.
t�I am a principal executive officer for the permitted MS4.
❑ I am a duly authorized representative for the permitted MS4 and have attached the authorization
made in writing by the permit owner listed in Part I of this application, which specifies me as (check
one):
❑ A specific individual having overall responsibility for the stormwater permit.
❑ A specific position having overall responsibility for the stormwater permit.
�/7
Signature:*
Print Name: Richard D. Cappola
Title: Interim Town Manager
Signed Au�<Tfday of 20 2a.
*Please note that an orioinal signature is required on this form, any required supplemental information, and any
representative authorization. Photocopies cannot be accepted.
Return this completed form along with the required supplemental information to:
DEQ-DEMLR Stormwater Program
Attn: MS4 Permitting
1612 Mail Service Center
Raleigh, NC 27699-1612
RECEIVE®
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LAND QUALITY SECTION
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