WQ0023238_Application_20181115

DWR
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Division of Water Resources
I. EXISTING PERM ITTEE INFORMATION:
State of North Carolina
Department of Environmental Quality
Division of Water Resources
SEWER SYSTEM PERMIT OWNERSHIP/NAME CHANGE
INSTRUCTIONS FOR FORM: PNOCF 01-16
1. Permittee's name: Waterside Crossing Residential, LLC
2. Signature authority's name: Larry Griffin. Jr. per 15A NCAC 02T .0106(b)
3. Signature authority's title: Managing Member
4. Permittee's mailing address: 19109 W Catawba Ave.. Suite 110
City: Cornelius State: North Carolina Zip: 28031-
RECEIVED/NCDENR/DWR
NOV 15 nm
WQROS
MOORESVILLE REGIONAL OFFICE
5. Permittee's contact information: Phone number: [phone] Fax Number
Email Address: larryjr rr.griffinbrothers.com
H. APPLICANT INFORMATION:
1. Applicant's name: Lincoln County
2. Signature authority's name: Donald V. Chamblee per 15A NCAC 02T .0106(b)
3. Signature authority's title: Director of Public Works
4. Applicant's mailing address: 115 West Main Street
City: Lincolnton State: NC Zip: 28092
5. Applicant's contact information: Phone number: (IQ43 736-8497 Fax Number (704) 7364499
Email Address: dchambleealincolncounty.org
6. Representative's name: Olan C Henderson
7. Representative's title: Engineering Associate
8. Representative's contact information Phone number: [phone] Fax Number [phone]
Email Address: [e-mail]
III. PERMIT INFORMATION:
1. Existing permit number: W00023238 and most recent issuance date: November 4, 2003
2. Reason for the permit application: Name Change If other, attach detailed explanation
3. Has the facility been constructed? N Yes or ❑ No
4. Has the facility been certified per 15A NCAC 02T .0116? ❑ Yes or N No
FORM: PNOCF 01.16 Page 1 of 2

IV. CERTIFICATIONS:
Existing Permittee's Certification per 15A NCAC 02T .0106(b):
that this application
Authority's named title from Application Item 1.2 & 3)
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, I will continue to be responsible for compliance with the current permit and any discharge of wastewater
from this system to surface waters or the land may result in an enforcement action that may include civil penalties, injunctive relief,
and/or criminal prosecution. I will also 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 are note completed and that if all required supporting
information and attachments are not included, this application will be returned to me as incomplete.
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 w—ee'/{}as c� it pen6fies to $25,000 per violation.
Signature: U ��Date: It log
Applicant's Certification per 15A NCAC 02T .0106(b):
1, Donald V. Chamblee Director of Public Works attest that this application
(Signature Authority's name & title from Application Item 11.20.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that after issuance of the permit into
the Applicant's name, I will be responsible for compliance with the issued permit and any discharge of wastewater from this non -
discharge system to surface waters or the land may 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.
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 w+n
well as civil penalties up to $25,000 per violation.
Signature: � _y- l A^ ' Date:
FORM: PNOCF 01-16 Page 2 of 2