WQ0017791_Renewal (Application)_20191114

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
Division of Wager Resources NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 08-19
This form is for renewal without modification for all non -discharge system permits, ezceat 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: City of Goldsboro
2. Signature authority's name: Timothy Salmon per 5A NCAC 02T .0106(h� Title: CitMana_gDjT4CDEig(DwR
Primary Telephone number: 19 580-4331 Select Secondary number: (_) - Select
Email Address: TSahnon ir_::oldsboronc.gov 4 ei1
3. Permittee's mailing address: Post Office'Drawer A
City: Goldsboro State: NC Zip: 27533-9701 Non-Disch U t
permitting
4. Billing address (if different from above):
City: State: Zip:
5. Contact person's name (if different from signature authority): Michael W g* er Title: Public Utilities Director
Primary Telephone number: 9I9 735-3122 Select Secondary number: [phone] Select
Email Address: MWaaner ii!_,oldsboroncxov
IL PERMIT INFORMATION:
I. 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 .01051
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 NNW Car lina 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 .0115taH 1 i]
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 — Oaerational A�nreement_�FORM: HOA and a copy of the proposed or
approved Articles of Incorporation, Declarations, and By-laws [15A NCAC 02T .0115s' c w j
• For Developers of lots to be sold — Operational A reement t FO DE _ [15A NCAC 02T .0115 b !]
FORM: NDSR 02-19 Page 1 of 3

BE MORE DO MORE SEYMOUR
Public Udifts
Post Office Drawer A
Goldsboro, NC 27533
Phone [phone]
November 14, 2019
PUBLIC UTILITIES DEPARTMENT
Michael Wagner, Public Utilities Director
www.,-goldsboronc..go v
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES RECEIVED/NCDEQ/DWR
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE BRANCH NOV 14 2019
Non-Dischar e.Re ortsgncdenr. ov
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.
Sincerelyall
4
•� �l T
Michael Wagner
Public Utilities Director
[phone]
enc.
electronic cc: Robert Tankard, NC DWR Washington Regional Office
Robert Sherman, Goldsboro WRF Superintendent

DWR
DCvWon of Water Resources
V. RELATED PERMITS
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 08-19
1. If this permit has interactions with other wastewater permits (collection systems, NPDES, etc.), complete the table below
(provide additional pages if necessary):
Permit T► Pe
NPDES
Permit No.
NCO023949
Collection &,stem
WQCS00023
Description
Wastewater (Pipe 001 and 002)
Wastewater Collection System
2. Does the facility have an approved flow reduction 15A NCAC 02T .0114 fil? ❑ 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 1SA NCAC 02T .0106; b is
I, Michael P. Wa--ner, 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 .0106i b i. Per 15A NCAC 02T .01061 c, an alternate person may be designated as the signing official if a delegation
letter is provided from a person wl o m ets the criteria in 15A NCAC 02T .0106r b +
Signature: Date: November 14.2019
��EE��VEDINCDE611DW13
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SMITTED TO:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY Nov 14 2019
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE BRANCH perm
scharge
Peemitting Unit
B% U.S. Postal Service: BA Courier: By Email:
Non -Discharge Branch Non -Discharge Branch — Archdale 640D Non-Discharge.Ret,orts u.ncdenr.i2ov
1617 Mail Service Center 512 N. Salisbury St.
Raleigh, NC 27699-1617 Raleigh, NC 27604
TELEPHONE NUMBER: [phone]
FORM: NDSR 02-19 Page 3 of 3

State of North Carolina
Department of Environmental Quality
DWRk Division of Water Resources
Division of Water Resources NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 08-19
III. SITE MAP:
1. Provide an updated site map in accordance with 15A NCAC 02T0I05t da 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 'c'ECUVED/NCDEQ/DWP
❑ Distance measurements verifying all setbacks are being met
❑ Stormwater drainage controls NOV 14 2019
❑ 100-year floodplain (if applicable)
❑ For reclaimed water generation permits oAh;,-, provide a separate map showing all distribution liawisaftodon permit
locations that are connected to the water generation facility and are permitted by the Non-Dis i9i (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 PParcelNo.
rantor or
Ty
Grantee
Expiration County
Date Re;istered
a. The document description shall list any reduced setbacks with distance, etc.
2. For reclaimed water utilization permits only:
Deed I Deed Page I Document
Book . —Description
Is reclaimed water utilized on property W 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.050 1{ 6). All documents shall be listed
in the table above.
FORM: NDSR 02-19 Page 2 of 3