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Home My WebLink AboutWQ0019782_Application_20200409State of North Carolina Department of Environmental Quality DWR Division of Water Resources NON -DISCHARGE SYSTEM RENEWAL Division of Water Resources FORM: NDSR 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 Non -Discharge Branch Website. L PERMITTEE INFORMATION: RECEIVED ECEI VED 1. Permittee: Rhonda Anderson By Nathaniel Thornburg at 10:27 am, Apr 09, 2020 2. Signature authority's name: Jamie Cosson per 15A NCAC 02T .0106(b) Title: Executive Director Primary Telephone number: 3( 36) 697-0525 Select Secondary number: 3( 36) 430-7653 Select Email Address: Jamie campweaver.org 3. Permittee's mailing address: 620 Green Valley Rd, Suite 210 City: Greensboro State: NC Zip: 27408-7725 4. Billing address (if different from above): City: State: Zip: - 5. Contact person's name (if different from signature authority): Title: Primary Telephone number: (_) = Select Secondary number: (_) = Select Email Address: IL PERMIT INFORMATION: 1. Existing permit number: WQ0019782 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 Penmittee 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. [15A NCAC 02T .0115(a)(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 [15A NCAC 02T .0115(c)] • For Developers of lots to be sold — Operational Agreement (FORM: DEV) [15A NCAC 02T .0115(b)] FORM: NDSR 09-19 Page 1 of 4 State of North Carolina Division of Water Resources 6. Does the facility treat and dispose of industrial wastewater? Department of Environmental Quality Division of Water Resources NON -DISCHARGE SYSTEM RENEWAL FORM: NDSR 09-19 If yes, complete items below. If no, skip to the next section. Indicate the approximate percentage of wastewater makeup: Industrial: % Domestic: % Stormwater: % For all industrial wastewater sources (excluding those permitted under a pretreatment permit), 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 Has the nature of wastes (e.g., change in industrial processes, introduction of new materials or chemicals, etc.) described in the approved permit application(s) changed? ❑ Yes or ❑ No If yes, a permit modification request shall be submitted to the Division. [G. S. 141-215. l(d)] III. SITE MAP: 1. Provide an updated site map in accordance with 15A NCAC 02T .0105(d) that shows the following (if applicable): 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, and scale ® Topographic contours on all disposal sites ® 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/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 ❑ For reclaimed water generation permits, 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. FORM: NDSR 09-19 Page 2 of 4 DWR Division of Water Resources IV. GROUNDWATER MONITORING WELLS State of North Carolina Department of Environmental Quality Division of Water Resources NON -DISCHARGE SYSTEM RENEWAL FORM: NDSR 09-19 1. Does the facility have a proposed or existing groundwater monitoring well network? ❑ Yes or ® No 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 a Longitude " Gradient Location Select 0- Select Select Select 0- Select Select Select 0- Select Select Select 0- Select Select Select 0- Select Select Select 0- Select Select Select 0- Select Select Select 0- Select Select Select 0- Select Select Select - Select Select a. Coordinates must be in NAD83 and have 6 decimal degrees V. SETBACK WAIVERS, EASEMENTS, AND LEASES: 1 2 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 Type Grantor or Parcel No. Grantee Expiration Date County Registered Deed Book Deed Page Document Description a Select Select Select Select Select Select Select a. The document description shall list any reduced setbacks with distance, etc. For reclaimed water utilization permits: Is reclaimed water utilized on property not 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 09-19 Page 3 of 4 State of North Carolina DWR Division of Water Resources VI. RELATED PERMITS Department of Environmental Quality Division of Water Resources NON -DISCHARGE SYSTEM RENEWAL FORM: NDSR 09-19 1. If this permit has interactions with other wastewater permits (collection systems, NPDES, etc.), complete the table below (provide additional pages if necessary): Permit Type Permit No. Description 2. Does the facility have an approved flow reduction [15A NCAC 02T .0114(f)]? ❑ 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 15A NCAC 02T .0106(b) I, Rhonda Anderson, 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 yo meets the criteria in 15A NCAC 02T .0106(b) Signature: Date: 5YJAW 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 By U.S. Postal Service: By Courier: By Email: Non -Discharge Branch Non -Discharge Branch — Archdale 942W Non-Discharge.Reportskncdenr.gov 1617 Mail Service Center 512 N. Salisbury St. Raleigh, NC 27699-1617 Raleigh, NC 27604 TELEPHONE NUMBER: (919) 707-3654 FORM: NDSR 09-19 Page 4 of 4 _ T1'Pifl-L --- KEEP QLJT --- wr1SrEYraTER DISPOSAL AP. g r - w _ �J r� �- �:,��1 f�•� rrr - - � - �- ,� -. - - ' r� � r l •� � � l�-,y�-~ --� •��r~� WRAF{IG' Sukze r vIAn:Ay zv � �' • r., 1 '? 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BARN Ex -1 a CABINS — — — — — —��iea _D SETS\ - — ------ L ;wrtEr 5 —7- F'I ExtSTING --------------- ------ ILL, I, IT, IR NO 0, IT AIR 1 A. 1 ----------- ------------- I SEAEOT S11 WAIATEIVANCE ------------------- WICINITY p -—PI — — — mw cob"t IL TEp.IC.E7-MTPcwIT, , , — — — — — — A', NO - IT, x, 7.Tr- _p N1AI LIP, Al MEAN, I—. fa _LA` I ILL APPIR ... AIE ADRAIL i� — Or, HEALTH Of)( Exf,; plwri S— DATA. TOTAL SITE ACREAGE ZONING` TO MAPo IIR LIED 8lLLEEFTA DOCK/PAGE 04EAPITL _F USNE, STSEE(IEA.B LFFEEI iT7NG FIN -------- ---------------------- OWNER: YMCA OF GREENSBORNO 620 GREEN VALLEY ROAD, SUITE 210 C REENESCROO, NNI 27PMERI CONTACT: JAMIE COSSON (252I6) E97-25 TI-1 ACRES MIXED LESE_nM ACIL-4221-4-1 129fIED CAMP(WC=3) ,IEFFERSONI PARKING DATA: REOUIRED PARKING: I SPACIO S.F. OF POOL AREA 14.90D /IOD E.F. - 1Q SPACES REWIRED TOTAL SPACES 11.1NDEEL - IEEE SPACES (ENCL 10 H/C) —0 I RA �I�IMIITOVR�TOLALP —TE ALL EXIIITA ILINLITIES FILE TO PAII- IIM 2. 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B412B6.90 TOP 655.5 E 1]19929.83 INV. IN 650.00 CNLORttJATOR / / TAN. MANN01£ N .OUT 849.90 OUPLEX RIMP 6TATON N0P + 655.0 INV. IWT 640.80 o-''`, / CLEAR AS REOUIREO E00 ip a• Py0 ,� c,' ` /� ' 6" SERNCE UNE FROM CABIN6 / �\ : B 13 6 38 / _ _' — (SEE SHEET CLO E:iT19425.]4 SILT FENCE BASIN PHASE 1 DEVELOPMENT TAN. MANHOLE 1 / SEEe - 1'•/0' VMT. PLANS) STA 0+00 _ 1'µ� VERT. To 652.5 ' LIAAT - 3 N(W) 646.80 � �I INV IN`N) 64B BO � + � ' ` �Or ► � � INV. OUT 648.70 APPROX. 100 YEAR F1000 I#00 3+00 2'F00 1+00 0+0 E vanoN fi .o 5+F00 4+00 3'b00 ZWlG 1+00 0#00 BO BA 0 EEL POST A MINIMUM OF 18" INTO GROUND ANC EXCAVATE A 6"x6' TRENCH LONG THE LINE OF POSTS. MAX 10; SPACING BETWEEN POSTS. MRE FENCE TO POSTS AND EXTEND THE BOTTOM OF THE FENCE 6' INTO THE :D TRENCH. 'HE FILTER FABRIC TO THE WIRE FENCE AND EXTEND THE BOTTOM OF THE INTO THE TRENCH. THE TRENCH AND COMPACT THE p57 STONE FIRMLY TO ANCHOR THE BOTTOM ILT FENCE SO 'HAT RUNOFF IS FORCED TO GO TiRU THE FENCE AND CANNOT R IT. NE SILT FENCE DETAIL s-a NOT aaR's MpDy�pMr�Of F,lyA'�G D LL %Xus�.m. PFR ASIM -0 V A$ SREL REINfLWG/:c 111 MEFT �sq)ryd�//Tepi ai� aa' A Anp X0" VFW INIH SRAS MANHOLES MAX. P/PE O.O. eur aA .saez ,arcn • PWiOAST )NNFT (CPDau(1 secnav A —A SANITARY MANHOLE DETAIL Rom 4 (ia uilx"riurms) iao-im ies. ne. =1I 11 (e)`xe¢u� issrcav I..Les.ID ac. io-osr. is t xrr�i'ioi TIL 11 eniu°P m us. ,x...xo .wusr �°17)urcnra r, s�owmss uo a �cw.ix pur es xwrr.T wm NMI 1. FL IIIim. xu. I—.�iejT SEEDING SPECIFICATIONS DE7ALL s- NOT To SOxm 2 PLAN NOTE' USE THIS RING AND COVER IN NON -PAVED AREAS TERN 25 1/4' 23 3/4' 3/4' 8-23 1/2" /a. 5 1/ ' 33' SECTION RING - 218 LBS. CDVER - 115 LBS. TOTAL - 333 LBS. MANHOLE RING TO BE ANCHORED WITH 1/2' REDHEAD STAINLESS STEEL ANCHORS AND SEALED BETWEEN RIND AND CONE W/BITUMASMC SEALER RING & COVER DETAIL ss—s NOT To cn� s —FORD, aom wAaITD siax1A OR mwW sf. x'D"Ax'ow""Aomao"m SECTION p`x PLAN pq tt1eR f�Belt xFAE 9 JAN ff5 200t uiyitueslgns, P.A. 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