WQ0037499_Application_20200508

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE PERMIT OWNERSHIP/NAME CHANGE
Division of Water Resources INSTRUCTIONS FOR FORM: NDPONC 06-16 & SUPPORTING DOCUMENTATION
This form is for ownership changes or name changes of a non -discharge system permit. Please note that "Permittee"
references the existing permit holder, and that "Applicant" references the entity applying for the ownership/name change.
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit website
A. Non -Discharge Permit Ownership/Name Change (FORM: NDPONC 06-16) Application (All Applications):
❑ Submit an original completed and appropriately executed Non -Discharge Permit Ownership/Name Change (FORM: NDPONC
06-16) application.
❑ The Existing Permittee'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 who
meets the criteria in 15A NCAC 02T .0106(b).
❑ 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 who meets the criteria
in 15A NCAC 02T .0106(b).
B. Existing Permit (All Applications):
❑ Submit a copy of the most recently issued permit.
C. Property Ownership Documentation (All Applications):
➢ Per 15A NCAC 02T .0504(f), 15A NCAC 02T .0604(e), 15A NCAC 02T .0704(f), 15A NCAC 02T .0804, 15A NCAC 02T
.1004(d), 15A NCAC 02T. I 104(d)(7), 15A NCAC 02T .1104(e)(5), 15A NCAC 02U .0201(c) or 15A NCAC 02U .0202(f),
the Applicant shall demonstrate they are the owner of all property containing the non -discharge system facilities:
❑ Legal documentation of ownership (i.e., GIS, deed or article of incorporation), or
❑ Written notarized intent to purchase agreement signed by both parties with a plat or survey map, or
❑ Written notarized lease agreement that specifically indicates the intended use of the property and has been signed by both
parties, as well as a plat or survey map. Lease agreements shall adhere to the requirements of 15A NCAC 02L .0107.
D. Certificate of Public Convenience and Necessity (All Applications where the Applicant is a Privately -Owned Public Utility):
❑ Per 15A NCAC 02T .0115(a)(1), provide one copy 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.
E. Operational Agreements (All Applications where the Applicant is a Home/Property Owners' Association or Developer of lots to
be sold):
➢ Home/Property Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit an original properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit an original proposed or approved Articles of Incorporation, Declarations and By-
laws.
➢ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit an original of the properly executed Operational Agreement (FORM: DEV).
F. Operation and Maintenance Agreement (All Applications for Single -Family Wastewater Irrigation Systems):
❑ Per 15A NCAC 02T .0604(h), submit an original of a notarized Operation and Maintenance Agreement (FORM: SFRWWIS
O&M) that has been signed and dated by all deeded property owners.
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 PERMITTING UNIT
By U.S. Postal Service: By Courier/Special Deliverv:
1617 MAIL SERVICE CENTER 512 N. SALISBURY ST.
RALEIGH, NORTH CAROLINA 27699-1617 RALEIGH, NORTH CAROLINA 27604
TELEPHONE NUMBER: [phone] FAX NUMBER: [phone]
INSTRUCTIONS FOR FORM: NDPONC 06-16 & SUPPORTING DOCUMENTATION Page 1 of 1

State of North Carolina
nWR Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE PERMIT OWNERSHIP/NAME CHANGE
Division of Water Resources FORM: NDPONC 06-16
L EXISTING PERMITTEE INFORMATION:
1. Permittee's name: KC2 Enterprises, LLC and 1-3, LLC
2. Signature authority's name: Bradley Zadell per 15A NCAC 02T .0106(b) Title: Manager
3. Permittee's mailing address: PO Box 1438
City: Apex State: NC Zip: 27502 -
4. Permittee's contact information: Phone number: (_) - Email Address:
5. Demonstration of historical consideration for permit approval — 15A NCAC 02T .0120:
Has the Permittee or any parent, subsidiary or other affiliate exhibited the following?
a. Has been convicted of environmental crimes under Federal law or G. S. 143-215.6B? ❑ Yes or ❑ No
b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or ❑ No
c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes or ❑ No
d. Is non -compliant with an existing non -discharge permit, settlement agreement or order? ❑ Yes or ❑ No
e. Has unpaid annual fees in accordance with 15A NCAC 02T .0105(e)(2)'? ❑ Yes or ❑ No
IL FACILITY INFORMATION:
1. Facility name: 282 Carolina Crossings Dr. SFR
2. Facility's physical address: 282 Carolina Crossings Dr.
City: Apex State: NC Zip: 27523 - County: Chatham
III. PERMIT INFORMATION:
1. Existing permit number: WQ00 37499 and most recent issuance date: 06/30/2015
2. Existing permit type: Single -Family Residence Wastewater Irrigation
3. Reason for the permit application: Change of Ownership
4. Has the facility been constructed? ❑Yes or 0 No
IV. APPLICANT INFORMATION:
1. Applicant's name: John and Juliet Dominic
2. Signature authority's name: John and Juliet Dominic per 15A NCAC 02T .0106(b) Title: Owners
3. Applicant's mailing address: 1058 UpchurchFarm Ln.
City: Cary State: NC Zip: 27519 -
4. Applicant's contact information: Phone number: ( ) - Email Address: iohndominic(�4botmail_com
5. Demonstration of historical consideration for permit approval — 15A NCAC 02T .0120:
Has the Applicant or any parent, subsidiary or other affiliate exhibited the following?
a. Has been convicted of environmental crimes under Federal law or G. S. 143-215.6B? ❑ Yes or 0 No
b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or 0 No
c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes or 0 No
d. Is non -compliant with an existing non -discharge permit, settlement agreement or order? ❑ Yes or 0 No
e. Has unpaid annual fees in accordance with 15A NCAC 02T .0105(e)(2)? ❑ Yes or 0 No
FORM: NDPONC 06-16 Page 1 of 2

Existing Permittee's Certification per 15A NCAC 02T .0106(b):
I, attest that this application for
(Signature Authority. s name & title from Application Item L2.)
(Facility name from Application Item IL 1.)
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, any discharge of wastewater from this non -discharge system to surface waters or the land will 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 the existing 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 as incomplete. I further certify that the existing Permittee or any affiliate 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 do not have any overdue annual
fees per 15A NCAC 02T .0105(e).
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.
Signature: Date:
Applicant's Certification per 15A NCAC 02T .0106(b):
John Dominic
I, attest that this application for
(Signature Authority's name & title from Application Item IV.2.)
282 Carolina Crossings Dr. SFR
(Facility name from Application Item IL 1.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that after reissuance of the permit
into the Applicant's name, any discharge of wastewater from this non -discharge system to surface waters or the land will 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. I further certify that the Applicant or any affiliate 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 do not have any overdue annual fees per 15A
NCAC 02T .0105(e).
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 $10,0 0 as well as ci it penalties up to $25,000 per violation.
05/08/2020
Signature: Date:
FORM: NDPONC 06-16 Page 2 of 2

State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEM
Division of Water Resources OPERATION AND MAINTENANCE AGREEMENT
FORM: SFRWWIS-O&M 09-18
Permit No. WQ00 37491 County: Select
Permittee: John Dominic (i.e., all deeded property owners)
The Permittee agrees to operate and maintain the single-family residence wastewater treatment and irrigation system as
follows:
1. Inspect the septic tank annually, and pump out solids as needed.
2. Inspect and clean the septic tank effluent filter annually. (if applicable)
3. Inspect the tablet chlorinator weekly. Add wastewater grade chlorine tablets (e.g., calcium hypochlorite) as
needed. Swimming pool grade chlorine tablets are not acceptable. (if applicable)
4. Inspect the ultraviolet disinfection unit weekly. Clean or replace the lamps and quartz sleeves as needed. (if
applicable)
5. Inspect all storage tanks, pumps, and alarms monthly. Remove the floating scum layer in all pump/storage tanks
when pumping the septic tank solids out.
6. Inspect the spray irrigation system monthly to verify: proper operation of the spray heads; that there are no leaks;
that vegetative growth does not obstruct the spray heads; that the irrigated wastewater is not ponding in or running
off the designated irrigation area; and that there are no objectionable odors. (if applicable)
7. Inspect the drip irrigation system monthly to verify: proper operation of the drip lines; that there are no leaks; that
vegetative growth does not obstruct the drip emitters; that the irrigated wastewater is not ponding in or running off
the designated irrigation area; and that there are no objectionable odors. (ifapplicable)
8. Maintain a set of Division -approved engineering plans and specifications.
9. Pay the required annual fee.
10. Request renewal of this permit on Division -approved forms no later than 180 days prior to expiration.
11. Sign and provide a hane of Ownership applicatio to any future owner of the single-family residence wastewater
treatment and irrigation system for their completion and submission to the Division of Water Resources.
We understand the above requirements and agree to these terms as part of the issued permit.
Signature: Date:
Signature:
Signature:
Signature:
Date:
Date:
Date:
05/08/2020
All deeded property owners shall sign this Operation and Maintenance Agreement
FORM: SFRWWIS-O&M 09-18 Page 1 of 1