WQ0017791_Renewal (Application)_20191118

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
WATER QUALITY REGIONAL OPERATIONS SECTION
NON -DISCHARGE APPLICATION REV%W REQUEST FORM
November 18, 2019
To: WaRO-WQROS: David May / Robert Tankard
From: Tessa Monday, Water Quality Permitting Section - Non -Discharge Branch
Permit Number: WQ0017791
Applicant: City of Goldsboro
Owner Type: Municipal
Facility Name: Goldsboro WRF
Signature Authority: Timothy Salmon
Address: PO Drawer A, Goldsboro, NC 27533-9701
Fee Category: Non -Discharge Major
Comments/Other Information:
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Permit Type: Reclaimed Water
Project Type: Renewal
Owner in BIMS? Yes
Facility in BIMS? Yes
Title: City Manager
County: Wayne
Fee Amount: $0 -Renewal
Attached, you will find all information submitted in support of the above -referenced application for your review,
comment, and/or action. Within 45 calendar days, please take the following actions:
® Return this form completed. ® Return a completed staff report.
❑ Attach an Attachment B for Certification. ❑ Issue an Attachment B Certification.
When you receive this request form, please write your name and dates in the spaces below, make a copy of this sheet, and
return it to the appropriate Central Office Water Quality Permitting Section contact person listed above.
RO-WQROS Reviewer:
Date:
FORM: WQROSNDARR 09-15 Page 1 of 1

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
NORTH CAROLINA
Environmental Quality
November 18, 2019
TIMOTHY SALMON — CITY MANAGER
CITY OF GOLDSBORO
PO DRAWER A
GOLDSBORO, NORTH CAROLINA 27533-9701
Subject: Acknowledgement of
Application No. WQ0017791
Goldsboro WRF
Reclaimed Water System
Wayne County
Dear Mr. Salmon:
The Water Quality Permitting Section acknowledges receipt of your permit application and
supporting documentation received on November 14, 2019. Your application package has been assigned
the number listed above, and the primary reviewer is Tessa Monday.
Central and Regional Office staff will perform a detailed review of the provided application, and
may contact you with a request for additional information. To ensure maximum efficiency in processing
permit applications, the Division of Water Resources requests your assistance in providing a timely and
complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact
Tessa Monday at [phone] or [e-mail].
Sincerely,
Nathaniel D. Thornburg, Supervisor
Division of Water Resources
cc: Washington Regional Office, Water Quality Regional Operations Section
Permit File WQ0017791
D E Q�� North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 1 1617 Mail Service Center I Raleigh, North Carolina 27699-1617
NORTH GAROI INA -
roMn m e�wro�m.m,i a.dnY 919.707.9000

BE MORE DO MORE SEYMOUR
Public utilities
Post Office Drawer A
Goldsboro, NC 27533
Phone [phone]
November 14, 2019
PUBLIC UTILITIES DEPARTMENT
Michael Wagner, Public Utilities Director
wwmaoldsboronc.00v
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES RECEIVED/NCDEQ/DWR
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE BRANCH NOV 14. 1019
[e-mail]
Non -Discharge
RE: Non -Discharge Reclaimed Water Permit Renewal WQ0017791 Permitting unit
Dear Non -Discharge Branch,
The City of Goldsboro's current Reclaimed Water Permit expires on May 31, 2020.
Please find enclosed Non -Discharge System Renewal Form: NDSR 08-19 and attached
site maps. Please let me know if you have any questions or need any additional
information.
Thank you.
Sincerely,
Michael Wagner
Public Utilities Director
[phone]
enc
electronic cc: Robert Tankard, NC DWR Washington Regional Office
Robert Sherman, Goldsboro WRF Superintendent

State of North Carolina'
DWR
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
Division of Wi�fier Resources FORM: NDSR 08-19
This form is for renewal without modification for all non -discharge system permits, except Residuals Management and Single -
Family Residence Wastewater Irrigation System permits.
For more information, visit the Water Quality Permitting Section's Non -Discharge Branch.
I. PERMITTEE INFORMATION:
1. Permittee: Cite of Goldsboro
2. Signature authority's name: Timothy Salmon per 15A NCAC 02T .0106(b) Title: City Mana_er
Primary Telephone number: 19 580-4331 Select Secondary number: (_) - elect
Email Address: TSahnonru,goldsboronc gov
3. Permittee's mailing address: Post Office Drawer A
City: Goldsboro State: NQ Zip: 27533-9701
RECEIVED/NCDEQ/DWR
4. Billing address (if different from above): NOV 14 2019
City; State: Zip:
5. Contact person s name (if different from signature authority): Michael Warner Title: Public Utilities on -Discharge
no I nit
Primary Telephone number: 919 7 5-IM Select Secondary number. (20 920-0760 Select
Email Address: MWa;ner tegoldsboronc.gov
II. PERMIT INFORMATION:
1. Existing permit number: WQ0017791
2. Has the facility been constructed? ® Yes or ❑ No
If yes, has the facility been constructed in accordance with the permit and the Division -approved plans and specifications?
(15A NCAC 02T .01101 ® Yes or ❑ No
If no, a formal permit modification request shall be submitted to the Division.
3. Has any of the property ownership within the facility and/or disposal area changed from what is indicated in the current permit
(Attachment B — disposal field owner/lessee)? ❑ Yes or ® No
Has the Permittee had a name change or has the permit changed ownership? ❑ Yes or ® No
If yes to either, a permit modification request shall be submitted to the Division. [15A NCAC 02T .0105]
4. Is this facility a Privately -Owned Public Utility? ❑ Yes or ® No
If yes, provide two copies 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.
[15A NCAC 02T .0115(a)(1)1
5. Is the Permittee a Home/Property Owners' Associations or Developers of lots to be sold? ❑ Yes or ®No
If yes, provide the following:
• For Home/Property Owners' Associations — Operational Agreement (FORM. HOA) and a copy of the proposed or
approved Articles of Incorporation, Declarations, and By-laws f 15A NCAC 02T .0115t c ► I
• For Developers of lots to be sold — Operational Agreement ( FORM: DEV) [15A NCAC 02T .0115(b i]
FORM: NDSR 02-19 Pagel of 3

I�
Division of Water Resources
III. SITE MAP:
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 08-19
1. Provide an updated site map in accordance with 15A NCAC 02T .0105cd1 that shows the following:
The site map is not required to be signed or sealed by a Professional Engineer. However, the map must indicate the source of
information. For example, parcel lines taken from a county GIS map should reference the GIS website.
❑ Legend, north arrow, scale, and legible in black and white
❑ Topographic contour intervals not exceeding 10 feet or 25 percent of total site relief
❑ Soil mapping units on all disposal sites
❑ All facility -related structures and fences within the treatment, storage, and disposal areas
❑ All habitable residences and places of assembly within 500 feet of all treatment, storage, and irrigations sites
❑ Location of all wells, streams (ephemeral, intermittent, and perennial), springs, lakes, ponds, ditches, and other surface
drainage features within 500 feet of all waste treatment, storage, and disposal site(s)
❑ Location and identification of each monitoring well (identify any background/upgradient wells)
❑ Latitude and longitude coordinates of all monitoring wells (decimal degrees to 6 digits)
❑ Location and identification of major components of the waste disposal system
❑ The wetted perimeter of all irrigation fields with field names (named according to the approved permit)
❑ Location and ownership of property boundaries within 500 feet of the disposal area (including road/rail right-of-ways)
❑ The delineation of compliance and review boundaries
❑ Distance measurements verifying all setbacks are being met
❑ Stormwater drainage controls
❑ 100-year floodplain (if applicable)
❑ For reclaimed water generationermits only, provide a separate map showing all distribution lines and utilization permit
locations that are connected to the water generation facility and are permitted by the Non -Discharge Branch (excludes
Local Program permitted facilities). Include all reclaimed water distribution line and reclaimed water utilization permit
numbers.
IV. SETBACK WAIVERS, EASEMENTS, AND LEASES:
1. Does the permit have any setback waivers, easements, or leases? ❑ Yes or ® No
If yes, provide copies of all documents and complete the table below:
Document
Tvpe
Grantor or
Parcel No. Grantee
Expiration
Date
County
Registered
Deed
Book
Deed Page
Document
Description'
Select
Select
1
Select
Select
0
Select
a. The document description shall list any reduced setbacks with distance, etc.
2. For reclaimed water utilization permits only:
Is reclaimed water utilized on property no controlled by the generator? ❑ Yes or ® No
A lease, easement, or agreement must be provided allowing for the utilization of reclaimed water on the property or within the
facility. For irrigation of reclaimed water, an easement is required per 15A NCAC 02U.0501(6 ►. All documents shall be listed
in the table above.
FORM: NDSR 02-19 Page 2 of 3

State of North Carolina
Department of Environmental Quality
Division of Water Resources
WR
DlvWon of Weser Resources FORM:
SYSTEM RENEWAL
FORM: NDSR 08-19
V. RELATED PERMITS
1. If this permit has interactions with other wastewater permits (collection systems, NPDES, etc.), complete the table below
(provide additional pages if necessary):
Permit Tv
NPDES
Collection Svstei
Permit No.
NC0023949—
WQCS00023
Wastewater (Pipe 001 and 002)
Wastewater Collection System
2. Does the facility have an approved flow reduction [15A NCAC 02T .0114(f)1? ❑ Yes or ®No
If yes, attach the measured monthly average amount of wastewater flow contributed per unit for the 12 months prior to permit
renewal. If any of these monthly averages are within 20% of the approved value, the Permittee shall provide a reevaluation of
the reduced flow value using the methodology applied to the original flow reduction application. Also, attach a copy of the
flow reduction approval letter.
Applicant's Certification per 15A NCAC 02T .0106(b):
I, Michael P. Wagner, attest that this renewal application has been reviewed by me, and is accurate and complete to the best of my
knowledge. I understand that any unauthorized 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 are not completed, this application may be returned to me as incomplete. I further certify that the Applicant or any parent,
subsidiary, or other affiliate of the Applicant 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 does not have any overdue annual fees.
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. 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 w o m is the criteria in 15A NCAC 02T .0106( b)
Signature: Date: November 14.2019
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED TO:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE BRANCH
% U.S. Postal Service: Bv Courier: BN Email:
Non -Discharge Branch Non -Discharge Branch — Archdale 640D Non-Dischar&j%VMW
1617 Mail Service Center 512 N. Salisbury St.
Raleigh, NC 27699-1617 Raleigh, NC 27604
NOV 14 2019
TELEPHONE NUMBER: [phone]
Non -Discharge
Permitting Unit
FORM: NDSR 02-19 Page 3 of 3

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