NC0049662_ATC application_20180419

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A. The Division of Water Resources will accept this application package for review only if all of the items are provided and the
application is complete. Failure to submit all of the required items will result in the application package being returned as
incomplete per 15A NCAC 02T .0105(b).
B. Plans and specifications must be prepared in accordance with 15 NCAC 02H. 0100, 15A NCAC 02T. North Carolina General
Statute 133-3, North Carolina General Statute 143-215.1, and Division of Water Resources Minimum Design Criteria for NPDES
Wastewater Treatment Facilities.
C. The plans and specifications submitted must represent a completed final design that is ready to advert
ise for bid.
D. Any content changes made to this Form ATC -12-14 shall result in the application package being returned.
E. The Applicant shall submit ONE ORIGINAL and ONE DIGITAL COPY (CD) of the application, all supporting documentation and
attachments. All information must be submitted bound or in a 3 -ring binder, with a Section tab for each Section, except the
Engineering Plans.
F. Check the boxes below to indicate that the information is provided and the requirements are met.
G. If attachments are necessary for clarity or due to space limitations, such attachments are considered part of the application
package and must be numbered to correspond to the item referenced.
H. For any project that requires review under the State Environmental Policy Act (SEPA), an Authorization to Construct cannot be
issued prior to the completion of a State Clearinghouse advertisement period for a FONSI, EIS, etc. unless the project qualifies
for a Determination of Minor Construction Activity.
I. For more information, visit the Division of Water Resources web site at: http://portal.ncdenr.org/web/wq/swp/ps/`npdes,
1. In addition to this Authorization to Construct, the Applicant should. be aware that other permits may be required from other
Sections of the Division of Water Resources (for example: reclaimed water facilities permits; Class A or B biosolids residuals
permit).
1 111 '111 iiil'�IIIIIIII
Applicant's name
Aqua North Carolina, Inc.
Signature authority's name per 15A NCAC 02T .0106(b)
Shannon Becker
Signature authority's title
President
Complete mailing address
202 MacKenan Drive, Cary, NC 27244
Telephone number
919-467-8712
Email address
[e-mail]
PROFESSIONAL ENGINEER
Professional Engineer's name
Benjamin D. Clawson
Professional Engineer's title
Project Engineer
North Carolina Professional Engineer's License No.
033710
Firm name
Municipal Engineering Services Co. P.A.
Firm License number
C-0281
Complete mailing address
68 Shipwash Drive Garner, NC 27529
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 1

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Telephone number
919-772-5393
Email address
[e-mail]
NPDES Permit number
NC0049662
Current Permitted flow (MGD) — include permit
0.25 MGD
flow phases if applicable
Provide a brief description of the project: The proposed prosect will consist of replacing the manual bar screen with an updated
auger type mechanical bar screen and bypass manual bar screen for redundancy. Scope of work will also include modifying
some piping to allow flows to properly enter and exit new screen tank.
® The letter must include a request for the Authorization to Construct; the facility NPDES Number; a brief project description
that indicates whether the project is a new facility, facility modification, treatment process modification, or facility
expansion; the construction timeline; and a list of all items and attachments included in the application package.
❑ If any of the requirements of 15 NCAC 02H. 0100, 15A NCAC 02T, North Carolina General Statute 133-3, North Carolina
General Statute 143-215.1, and Division of Water Resources Minimum Design Criteria for NPDES Wastewater Treatment
Facilities are not met by the proposed design, the letter must include an itemized list of the requirements that are not met.
B. NPDES Permit
® Submit Part I of the Final NPDES permit for this facility that includes Part A (Effluent Limitations and Monitoring
Requirements) for the monthly average flow limit that corresponds to the work that is requested for this project.
❑ If the facility is subject to any Special Orders by Consent (SOC), submit the applicable SOC.
® Not Applicable.
1111 IF 1111111111111111171112115
❑ Submit a copy of the Finding of No Significant Impact or Record of Decision for this project.
❑ Provide a brief description of any of the mitigating factors or activities included in the approved Environmental Document
that impact any aspect of design of this project, if not specified in the Finding of No Significant Impact or Record of Decision
® Not Applicable.
E. Engineering Plans
® Per 15A NCAC 02T .0504(c)(1), submit one set of detailed plans that have been signed, sealed and dated by a North Carolina
Licensed Professional Engineer.
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 2

ENd IRONt✓ENTfAL zOUALUTY
State of North Carolina
Division of •
® Per 21 NCAC 56 I the name, address and License number of the Licensee's firm shall be included on each sheet of
the engineering drawings.
® Plans must be labeled as follows: FINAL DRAWING —FOR REVIEW PURPOSES ONLY —NOT RELEASED FOR CONSTRUCTION.
® 15A NCAC 02H .0124 requires multiple (dual at a minimum) components such as pumps, chemical feed systems, aeration
equipment and disinfection equipment. Is this requirement met by the design? ® Yes or ❑ No. If no, provide an
explanation:
Plans shall include:
❑ Plans for all applicable disciplines needed for bidding and construction of the proposed project (check as appropriate):
® Civil ❑ Not Applicable
® Process Mechanical
® Structural
® Electrical
❑ Instrumentation/Controls
❑ Architectural
❑ Building Mechanical
❑ Building Plumbing
❑ Not Applicable
❑ Not Applicable
❑ Not Applicable
® Not Applicable
® Not Applicable
® Not Applicable
® Not Applicable
® Plan and profile views and associated details of all modified treatment units including piping, valves, and equipment
(pumps, blowers, mixers, diffusers, etc.)
❑ Are any modifications proposed that impact the hydraulic profile of the treatment facility? ® Yes or ❑ No. If yes, provide
a hydraulic profile drawing on one sheet that includes all impacted upstream and downstream units. The profile shall
include the top of wall elevations of each impacted treatment unit and the water surface elevations within each impacted
treatment unit for two flow conditions: (1) the NPDES permitted flow with all trains in service and (2) the peak hourly flow
with one treatment train removed from service.
❑ Are any modifications proposed that impact the process flow diagram or process flow schematic of the treatment facility?
❑ Yes or ❑ No. If yes, provide the process flow diagram or process flow schematic showing all modified flow paths
including aeration, recycle/return, wasting, and chemical feed, with the location of all monitoring and control instruments
noted.
F. ® Engineering Specifications
® Per 15A NCAC 02T .0504(c)(2), submit one set of specifications that have been signed, sealed and dated by a North Carolina
Licensed Professional Engineer.
® Specifications must be labeled as follows: FINAL SPECIFICATIONS —FOR REVIEW PURPOSES ONLY —NOT RELEASED FOR
CONSTRUCTION.
Specifications shall include:
® Specifications for all applicable disciplines needed for bidding and construction of the proposed project (check as
appropriate):
® Civil El Not
Applicable
® Process Mechanical ❑Not Applicable
® Structural ❑Not Applicable
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 3

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EN`dIRONMENTAL. QUALITY
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® Electrical
❑ Instrumentation/Controls
❑ Architectural
❑ Building Mechanical
❑ Building Plumbing
❑Not Applicable
® Not Applicable
® Not Applicable
® Not Applicable
® Not Applicable
® Detailed specifications for all treatment units and processes including piping, valves, equipment (pumps, blowers, mixers,
diffusers, etc.), and instrumentation.
® Means of ensuring quality and integrity of the finished product including leakage testing requirements for structures and
pipelines, and performance testing requirements for equipment.
❑ Bid Form for publically bid projects.
G. Construction Sequence Plan
® Construction Sequence Plan such that construction activities will not result in overflows or bypasses to waters of the State.
The Plan must not imply that the Contractor is responsible for operation of treatment facilities. List the location of the
Construction Sequence Plan as in the Engineering Plans or in the Engineering Specifications or in both: Sequence Plan is laid
out as part of the Engineering Plans.
H. Engineering Calculations
® Per 15A NCAC 02T .0504(c)(3), submit one set of engineering calculations that have been signed, sealed and dated by a
North Carolina Licensed Professional Engineer; the seal, signature and date shall be placed on the cover sheet of the
calculations.
For new or expanding facilities and for treatment process modifications that are included in Section 4.C, the calculations shall
include at a minimum:
❑ Demonstration of how peak hour design flow was determined with a justification of the selected peaking factor.
❑ Influent pollutant loading demonstrating how ea influent characteristics in Section 4.B.2 of this form were
determined.
❑ Pollutant loading for each treatment unit demonstrating how the design effluent concentrations in Section 4. B.2 of this
form were determined.
❑ Hydraulic loading for each treatment unit.
❑ Sizing criteria for each treatment unit and associated equipment (blowers, mixers, pumps, etc.)
❑ Total dynamic head (TDH) calculations and system curve analysis for each pump specified that is included in Section 4.C.6.
❑ Buoyancy calculations for all below grade structures.
❑ Supporting documentation that the specified auxiliary power source is capable of powering all essential treatment units.
I. Permits
® Provide the following information for each permit and/or certification required for this project:
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 4
Permit/
If Not Issued Provide
Not
Date
Date
Certification
Status and Expected
Permit/Certification
Applicable
Submitted
Approved
Number
Issuance Date
Dam Safety
X
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 4

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ENViRONMENTA.L 4:aLEAI_ TY
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Soil Erosion and Sediment Control
X
USCOE / Section 404 Permit
X
Water Quality Certification (401)
X
USCOE /Section 10
X
Stormwater Management Plan
X
CAMA
X
NCDOT Encroachment Agreement
X
Railroad Encroachment Agreement
X
Other:
Residuals Management Plan
❑ For all new facilities, expanding facilities, or modifications that result in a change to sludge production and/or sludge
processes, provide a Residuals Management Plan meeting the requirements of 15A NCAC 02T .0504(1) and .0508; the Plan
must include:
❑ A detailed explanation as to how the generated residuals (including trash, sediment and grit) will be collected, handled,
processed, stored, treated, and disposed.
❑ An evaluation of the treatment facility's residuals storage requirements based upon the maximum anticipated residuals
production rate and ability to remove residuals.
❑ A permit for residuals utilization or a written commitment to the Applicant from a Permittee of a Department approved
residuals disposal/utilization program that has adequate permitted capacity to accept the residuals or has submitted a
residuals/utilization program application.
❑ If oil, grease, grit or screenings removal and collection is a designated unit process, a detailed explanation as to how
the oil/grease will be collected, handled, processed, stored and disposed.
® Not Applicable.
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 5

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ENVIRONMENTAL. QUAL TY
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1. Provide the following flow information:
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 6
Plant Flows
Existing Plant Design
0.25 MGD
Current NPDES Permit Limit
0.25 MGD
Current Annual Average
(past 12 months)
0.123 MGD
For Past 12 Months:
Start Date: Oct 2017
End Date: Nov 2016
For Past 24 Months:
Start Date: Oct 2017
End Date: Jan 2016
Maximum Month
0.13 MGD
0.14
MGD Jan 2016
Maximum Day
0.32 MGD
0.32
MGD Apr 2017
Peak Hour
[Data not Available] MGD
[Data not Available] MGD
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 6

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G NVIRONMENT. L GUAUTY
State of North Carolina
partment of Environmental Quality
ResourcesDivision of Water
FOR TREATMENT PROCESS MODIFICATIONS
1. Have all of the requirements of 15 NCAC 02H. 0100, 15A NCAC 02T, North Carolina General Statute 133-3, North Carolina
General Statute 143-215.1, and Division of Water Resources Minimum Design Criteria for NPDES Wastewater Treatment
Facilities been met by the proposed design and specifications? ® Yes or ❑ No. If no, provide justification as to why the
requirements are not met, consistent with 15A NCAC 02T .0105(n):
2. Provide the design influent and effluent characteristics that are used as the basis for the project design, and the NPDES
permit limits for the following parameters:
Estimated, based on
industry standards Project Basis of Design
and sampling at
other similar plants Design Influent Design Influent Design Effluent
owned by Aqua NC Concentration Load Concentration
Influent (Must be (Must be and/or Load
Concentration - supported by supported by
Engineering Engineering (Per Historic
Current Annual g g g g records from 1047
Average (past 12 Calculations Calculations
to 1-15
Parameter months) if Available (Section 3.H11 [Section 3.H1)
NPDES Permit Limits
(monthly average)
Ammonia Nitrogen 0.266 mg/L Summer 2.0 mg/L Summer
(NH3-N) 15 mg/L mg/L Ib/day
0.596 mg/L Winter 4.0 mg/L Winter
Total Kjeldahl
N itro�en
mg/L
Total Nitrogen
/year
16.0 mg/L Summer
30.0 mg/L Winter
200 per 100 mL
8.0 mg/L
I b/year
mg/L 1.0 mg/L
Total Phosphorus 2.0 mg/L mg/L Ib/day
Ib/year Ib/year
Total Suspended 150 mg/L mg/L Ib/day 3.49 mg/L 30.0 mg/L
Solids (TSS)
3. Based on the "Project Basis of Design" parameters listed above, will the proposed design allow the treatment facility to
meet the NPDES Permit Limits listed above? ®Yes or ❑ No. If no, describe how and why the Permit Limits will not be
met:
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 7

1? v cn`e rResources
ENVIRONMENTAL QUAL7Y
4. Per 15A NCAC 02T .0505(1), by-pass and overflow lines are prohibited. Is this condition met by the design? ®Yes or ❑ No
If no, describe the treatment units bypassed, why this is necessary, and where the bypass discharges:
5
Per 15A NCAC 02T .0505(k), multiple pumps shall be provided wherever pumps are used
design? ® Yes or ❑ No. If no, provide an explanation:
Is this condition met by the
6. Per 15A NCAC 02T .0505(1), power reliability shall be provided consisting of automatically activated standby power supply
onsite capable of powering all essential treatment units under design conditions, or dual power supply shall be provided
per 15A NCAC 02H. 0124(2)(a). Is this condition met by the design? ® Yes or ❑ No. If no, provide (as an attachment
to this Application) written approval from the Director that the facility:
➢ Has a private water supply that automatically shuts off during power failures and does not contain elevated water
storage tanks, and
➢ Has sufficient storage capacity that no potential for overflow exists, and
➢ Can tolerate septic wastewater due to prolonged detention.
7. Per 15A NCAC 02T .0505(0), a minimum of 30 days of residual storage shall be provided. Is this condition met by the
design? ® Yes or ❑ No. If no, explain the alternative design criteria proposed for this project in accordance 15A NCAC
02T .105(n):
8. Per 15A NCAC 02T .0505(g), the public shall be prohibited from access to the wastewater treatment facilities. Explain how
the design complies with this requirement: Existing fence around the perimeter of the facility with locked gate for entry
9. Is the treatment facility located within the 100 -year flood plain? ❑Yes or ®No. If yes, describe how the facility is
protected from the 100 -year flood:
1. PRELIMINARY AND PRIMARY TREATMENT (i.e., physical removal operations and flow equalization):
Treatmen+" ;t
Application for Authorization to Construct Permit (FORM ATC -12-141 Page 8
Calculations
No. of
Plan Sheet
Specific ation
Tye
V
Size per Unit
Provided?
Units
Reference
Reference
(Yes or No)
Huber—Manual
N
Manual Bar Screen
1
bypass screen built
_ MGD at peak hourly flow
C-2
into base tank of
mechanical screen
Huber—Auger
Special
Y
Mechanical Bar
1.59 MGD at peak hourly
1
type Mechanical
C-2
Equipment
Screen
flow
Bar Screen
1.0
MGD at peak hourly
Grit Removal
N/A
flow
Flow Equalization
N/A
ft diameter; ft
Primary Clarifier
N/A
Circular
side water depth
Primary Clarifier
N/A
Rectangular
square feet; ft
side water depth
Other
Application for Authorization to Construct Permit (FORM ATC -12-141 Page 8

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Application for Authorization to Construct Permit (FORM ATC -12-14) Page 9

CNVIRONMENTAL OUALITY
14)
State of North Carolina
Division of - •.
2. SECONDARY TREATMENT (BIOLOGICAL REACTORS AND CLARIFIERS) (i.e., biological and chemical processes to remove
organics and nutrients)
3. TERTIARY TREATMENT
Calculations
No. of
Plan Sheet
Specification
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided?
(Yes or No)
Aerobic Zones/
N/A
gallons
Tanks
N/A
Circular
hourly flow; number of
Anoxic Zones/
N/A
(Parallel; in
water depth
Tertiary Clarifier
Rectangular
gallons
Tanks
series)
water depth
Anaerobic
square feet
Tertiary Membrane
(Gas;
gallons
Zones/Tanks
tablet; liquid)
square
Sequencing Batch
--
gallons
Flow Equalization
--
gallons
Reactor (SBR)
gallons
Membrane
--
gallons
Bioreactor (MBR)
ft diameter; ft side
Secondary Clarifier
Circular
water depth
Secondary Clarifier
Rectangular
square feet; ft side
water depth
Other
3. TERTIARY TREATMENT
4. DISINFECTION
Calculations
No. of
Plan Sheet
Specification
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided?
(Yes or No)
ft diameter; ft side
Tertiary Clarifier
N/A
Circular
hourly flow; number of
Ultraviolet Light
N/A
(Parallel; in
water depth
Tertiary Clarifier
Rectangular
square feet; ft side
series)
water depth
Tertiary Filter
square feet
Tertiary Membrane
(Gas;
feet
Filtration
tablet; liquid)
square
Post -Treatment
--
gallons
Flow Equalization
Post -Aeration
gallons
Other
4. DISINFECTION
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 10
Calculations
No. of
Plan Sheet
Specification
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided?
(Yes or No)
gal/day per bank at peak
hourly flow; number of
Ultraviolet Light
N/A
(Parallel; in
banks; number of
series)
lamps/bank
(Gas;
gallons of contact
Chlorination
tablet; liquid)
tank/unit
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 10

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G N ViAOF1MENTAL DUALiTY
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•.' c• • •' • • •', '' •.
Dechlorination
No. of
Pumps
(Gas;
gallons of contact
Capacity of
each pump
Plan Sheet
Reference
Calculations
GPM
No. of
tablet; liquid)
tank/unit
Plan Sheet
Specification
5. RESIDUALS TREATMENT
L"
PUMP SYSTEMS (include influent, intermediate, effluent, major recycles, waste sludge, thickened waste sludge and plant
drain pumps)
Location
No. of
Pumps
purpose
Type
Capacity of
each pump
Plan Sheet
Reference
Calculations
GPM
No. of
EQ Basin
Plan Sheet
Specification
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided?
(Yes or No)
Gravity Thickening
N/A
square feet; ft side
Tank
water depth
Mechanical
Thickening/
dry Ib/hour
Dewatering
Aerobic Digestion
N/A
Anaerobic
gallons
Digestion
Composting
dry Ib/hour
Drying
dry Ib/hour
Other
PUMP SYSTEMS (include influent, intermediate, effluent, major recycles, waste sludge, thickened waste sludge and plant
drain pumps)
Location
No. of
Pumps
purpose
Type
Capacity of
each pump
Plan Sheet
Reference
Specification
Reference
GPM
TDH
EQ Basin
7. MIXERS
Location
No. of
Mixers
Purpose
Type
Power of
P fixer
(HP)
plan Sheet
Reference
Specification
Reference
N/A
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 11

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ENVIRONMENTAL QUAUTY
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Application for Authorization to Construct Permit (FORM ATC -12-14) Page 12

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ENVIRONMENTAL r4UAL:TY
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Location
No. of
Blowers
purpose
Type
Capacity of
each Blower
(CFM)
plan Sheet
Reference
Specification
Reference
N/A
Requirement met by the
Required from Nearest
Setback Parameter
TreatmentStorage
Design? If "No", identify
Setback Waivers in Item D.2
Unit
Below
Any habitable residence or place of assembly under separate
100 ft
® Yes
❑ No
ownership or not to be maintained as part of the project site
Any private or public water supply source
100 ft
® Yes
❑ No
Surface waters (streams — intermittent and perennial, perennial
50 ft
® Yes
❑ No
ODOR CONTROL
Location
No. of
Units
purpose
Type
Plan Sheet
Reference
Specification
Reference
N/A
Requirement met by the
Required from Nearest
Setback Parameter
TreatmentStorage
Design? If "No", identify
Setback Waivers in Item D.2
Unit
Below
SETBACKS —COMPLETE FOR NEW WASTEWATER TREATMENT STRU
1. The minimum distance for each setback parameter to the wastewater treatment/storage units per 15A NCAC 02T .0506(b)
are as follows:
2. Have any setback waivers been obtained per 15A NCAC 02T .0506(d)? El Yes or ®No. If yes, have these waivers been
written, notarized and signed by all parties involved and recorded with the County Register of Deeds? F1 Yes
Is Minimum Distance
Minimum Distance
Requirement met by the
Required from Nearest
Setback Parameter
TreatmentStorage
Design? If "No", identify
Setback Waivers in Item D.2
Unit
Below
Any habitable residence or place of assembly under separate
100 ft
® Yes
❑ No
ownership or not to be maintained as part of the project site
Any private or public water supply source
100 ft
® Yes
❑ No
Surface waters (streams — intermittent and perennial, perennial
50 ft
® Yes
❑ No
waterbodies, and wetlands)
Any well with exception of monitoring wells
100 ft
® Yes
❑ No
Any property line
50 ft
® Yes
❑ No
or ❑ No. If
no, provide an explanation:
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 13

EF4VIRO IE%TAL ry'i3AUTY
�-•. • •Sam
•
Professional Engineer's Certification per 15A NCAC 02T .0105:
I, Benjamin D. Clawson ,attest that this application package for an Authorization to Construct
(Typed Name of Professional Engineer)
for the Hawthorne WWTP Bar Screen Rehabilitation (NC0049662)
(Facility and Project Name)
was prepared under my direct supervisory control and to the best of my knowledge is accurate, complete and consistent
with the information supplied in the engineering plans, specifications, calculations, and all other supporting
documentation for this project. I further attest that to the best of my knowledge the proposed design has been
prepared in accordance with all applicable regulations and statutes, 15 NCAC 02H. 01001 15A NCAC 02T, North Carolina
General Statute 133-3, North Carolina General Statute 143-215.1, and Division of Water Resources Minimum Design
Criteria for NPDES Wastewater Treatment Facilities, and this Authorization to Construct Permit Application, except as
provided for and explained in Section 4.6.1 of this Application. I understand that the Division of Water Resources'
issuance of the Authorization to Construct Permit may be based solely upon this Certification and that the Division may
waive the technical review of the plans, specifications, calculations and other supporting documentation provided in this
application package. I further understand that the application package may be subject to a future audit by the Division.
Although certain portions of this submittal package may have been prepared, signed and sealed by other professionals
licensed in North Carolina, inclusion of these materials under my signature and seal signifies that I have reviewed the
materials and have determined that the materials are consistent with the project design.
I understand that in accordance with General Statutes 143-215.6A and 143-215.66, 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.
North Carolina Professional Engineer's seal with written signature placed over or adjacent to the seal and dated:
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 14

State of North Carolina
Department of Environmental Quality
sion of•Water Resources
V`>rater Resources
CNVMONMEN AL. GUALMr APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC -12-
14)
SECTION 6: APPLICATION CERTIFICATION BY AFPLlCANT
Applicant's Certification per 15A NCAC 02T .d106(h}:
f, Shannon seeker, President ,attest that this application package for an Authorization to Construct
(Typed Name of Signature Authority and Title) -
for the Hawthorne WWTP Bar Screen Rehabilitation (NCD049562)
(Facility and Project Name)
has been reviewed by me and is accurate and complete to the best of my knowledge. 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 in
accordance with 15A NCAC 02T ,0120(b), the Applicant or any affiliate has not been convicted of environmental crimes,
has not abandoned a wastewater facility without proper closure, does not have an outstanding civil penalty where all
appeals have been abandoned or exhausted, are compliant with any active compliance schedule, and does not have any
overdue annual fees.
I understand that the Division of Water Resources' issuance of the Authorization to Construct Permit maybe based
solely upon acceptance of the Licensed Professional Engineer's Certitication contained in Section 5, and that the Division
may waive the technical review of the plans, specifications, calculations and other supporting documentation provided
in this application package. I further understand that the application package maybe subject to a future audit.
I understand that in accordance with General Statutes 143-215.6A and 143-215.68 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 perviolation.
Signature:
Date: `- e
l
THE COMPLETED APPLICATION AND SUPPORTING INFORMATION SHALL BE SUBMITTED TQ:
NDRTH CAROLINA DEPARTMENT OF ENVIRQNMENT AND NATURAL RESOURCES
DIVISION DF WATER RESOURCES/NPDES
By U.S. Postal Service By Courier/Special Delivery
:
1611 MAIL SERVICE CENTER 512 N. SALISBURY STREEC, 9TH FLDOR
RALEIGH, NORTH CAROLINA 27699-1617 RALEIGH, NORTH CAROLINA 27604
TELEPHONE NUMBER: {919} 807-6396
Application for Authorization to Construct Permit (FORM ATC -12-141
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