WQ0002096_Application_20200102

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: INDSR 09-19
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 Nora -Discharge Branch Website.
I. PERMITTEE INFORMATION:
1. Permittee: W00002096
2. Signature authority's name: per ISA NCAC 02T .01 b Title: Qtifflu:-
Primary Telephone number: (= U5-_U 75 Select
Email Address: u [e-mail]
3. Permittee's mailing address: 240 S Early Station Road
City: Ahoskie, State: NC Zip: 2791.0
4. Billing address (if different from above): PO Box 369
Secondary number: (3q6 ) 595-1076 Select
RECEIVED/NCDEQ/DWR
JAN 0 2 202a
City: Ahoskie, State: NC Zip: 2791.0 � Non -Discharge
5. Contact person's name (if different from signature authority): OTiitle: &.,4* Permuting Unit
Primary Telephone .number: (U2.) 3aL-j?JL Select Secondary number: (�&) 4.7- y velect
Email Address:
rr►�i � t'(:yvt
IL PERMIT INFORMATION:
l . Existing permit number: WQ00 02096
2. Has the facility been constructed? X Yes or ❑❑ No
IV
If ves, has the facility been c ns cted in accordance with the permit and the Division -approved plans and specifications?
[15A NCAC 02T .0110 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 disp sa area changed from what is indicated in the current
permit (Attachment B — disposal field owner/lessee)? ❑❑ Yes or No
Has the Pertnittee had a name change or has the permit changed ownership? " Yes or No Name Change of the Facility not Owner
If yes to either, a permit modification request shall be submitted to the Division. [ 15A NCAC 02T .01051
4. is this facility a Privately -Owned Public Utility? rwwol 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_ [ i5A NCAC 02T .0115 a 1 j
5. Is the Permittee a Home/Property Owners' Associations or Developers of lots to be sold? ❑❑ Yes or No
LeNj
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 [15A NCAC 02T .0115(c)j
• For Developers of lots to be sold— Operational Agreement FORM: DEV 15A NCAC 02T.0115(bfl
FORM: NDSR 09-19 Page 1 of

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 09-19
6_ Does the facility treat and dispose of industrial wastewater? If yes, complete items below. If no, skip to the next sectioii
Provide a detailed industrial process description including:
An overview of the manufacturing process
An inventory of all materials used for manufacture, including chemicals and biological matter
An overview of cleaning and treatment methodology, including an inventory of treatment materials and compounds
Indicate the approximate percentage of wastewater makeup:
Industrial: % Domestic: 100 % Stormwater: pro
Has the nature of wastes (e.g., change in industrial process a, troducti:on of new materials or chemicals, etc.) described in
the approved permit application(s) changed? ❑[] yes or No
If ves, a permit modification request shall be submitted to the Division. G.S. 141-21.5.1(d))
1II. SITE MAP:
Provide an updated site map in accordance with 15A NCAC 02T .0105 dl 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 whit,-
❑ 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)
❑ 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:Irail right-of-ways)
❑ The delineation of compliance and review boundaries
❑ Distance measuremumts verifying all setbacks are being met
❑ Stonnwater drainage controls
❑ 100-year floodplain (if applicable)
❑ For reclaimed water generation permits only, provide a separate snap 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.
FORM: NDSR 09-19
Page 2 of 4

Division of Water Resources
IV. GROUNDWATER MONITORING WELLS
State of North Carolina
Department of Environmental Qualio,
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 09-19
Does the facility have a proposed or existing groundwater monitoring well network? ❑❑❑ Yes or XNo
If no, skip to next section.
If yes, complete the following table (NOTE — This table may be expanded for additional wells):
Well
Name
Status
Latitude
Longitude'
Gradient
Location
Select
_
Select
Select
Select
_
Select
Select
Select
_
Select
Select
Select
_
Select
Select
Select
_
Select
Select
Select
_
Select
Select
Select
_
Select
Select
Select
_
Select
Select
Select
_
Select
Select
Select
_
Select
Select
a. Coordinates must be in NAD83 and have 6 decimal degrees
V. SETBACK WAIVERS, EASEMENTS, AND LEASES:
1. Does the permit have any setback waivers, easements, or leases? ❑❑ Yes or IX No
If yes, provide copies of all documents and complete the table below:
Document
T e
Grantor or
Parcel No.
Grantee
Expiration
Date
County
Registered
Deed
Book
Deed
Page
Document
Description
Select
Select
Select
Select
Select
Select
Select
a. Che document description shall list any reduced setbacks with distance, etc.
2. For reclaimed water utilization permits only:
Is reclaimed water utilized on property not controlled by the generator? IX Yes or[]El 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(61. All documents shall be
listed in the table above.
FORM: NDSR 09-19 Page 3 of 4

DWR
Division of Water Resources
V1. RELATED PERMITS
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR M-19
1. if this permit has interactions with other wastewater permits (collection systems, NPDES, etc.), complete the table below
(provide additional pages if necessary):
Permit
2_ Does the facility have an approved flow reduction [ 15A NCAC 02T .011 t( t�]? 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 ISA NCAC 02T-0106tb1
I, Guy Pierce 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 surlace 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. 1 also understand that if all required parts
of this application are not completed, this application may be returned tome as incomplete, 1 further certify that the Applicant or am
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 tees.
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 he 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 .0106ib). Per 15A NCAC 02T .0106 c , an alternate person maybe designated as the signing official if a delegation
letter is provided from a person who meets the criteria in 15A NCAC 02T .0106(bl
A
Signature: f Date: —
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTA`I'107.,4- SHALL BE SUBMITTED TO:
NORTH CAROLINA DEPAKFMENT ON ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON-DISCIARGE BRANCH
By U.S. Postal Service: BY -Courier: By Email:
Non -Discharge Branch Non -Discharge Branch — Archdale 942W Non -Discharge. orts d ncdenr, ov 1617 Mail Service Center 512 N. Salisbury St.
Raleigh, NC 27699-1617 Raleigh, NC 27604
TELEPHONE NUMBER: [phone]
FORM: NDSR 09-19
Page 4 of 4

DWR
Dfvisfon of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 09-19
FORM: NDSR 09-19
Page 5 of 4