WQ0040599_Application (FTSE)_20200618

Permit Number WQ0040599
Program Category
Non -discharge
Permit Type
Gravity Sewer Extension, Pump Stations, $ Pressure Sewer Extensions
Primary Reviewer
dean.hunkele
Coastal SWRule
Permitted Flow
32,659
Facility
Central Files: APS _ SWP _
6/11/2020
Permit Tracking Slip
Status
Project Type
In review
Major modification
Version
Permit Classification
B
Individual
Permit Contact Affiliation
Facility Name Major/Minor Region
Leland Mixed Use Development Minor Wilmington
Location Address County
Brunswick
Facility Contact Affiliation
Owner
Owner Name Owner Type
Brunswick Regional Water and Sewer H2go Government - County
Owner Affiliation
Robert Walker
PO Box 2230
Dates/Events Leland NC 2845122:
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
3/8/2019 6/8/2020
Reaulated Activities
Office
Retail
Subdivision
Wastewater collection 17
Outfall
Waterbody Name
Requested /Received Events
Additional information requested T-5 _ f Y 16�'_nd� -
Additional information received �

June 8, 2020
Dean Hunkele
Water Quality Regional Operations Section
NCDEQ
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
RE: Permit No. W00040599
Leland Mixed Use Development
Wastewater Collection System Extension
Brunswick County
Dean:
ECEI E
JUN 0 8 2020
We are a requesting permit modification for the Leland Mixed Use Development. The Leland
Mixed Use project was annexed into Leland and as a result of this, we need to transfer the sewer
permit into Leland's name. The length of the forcemain has changed and we added a small amount
of gravity line. The permit application has been revised.
Attached are two copies of the revised permit application along with two copies of the FTSE forms
for Leland and Brunswick County. Two copies of revised narrative is also attached along with a
check for $480 for the application fee.
If you need anything else, please let me know
Sincerely,
Ma-k,,N. H"Vovev
Mark N. Hargrove
Port City Consulting Engineers, PLLC
PORT CITY CONSULTING ENGINEERS, PLLC
62 1 5 STONEEIRIDGE ROAD, W I L M I N G T O N, NO 2 B 4 D 9
P M 1 1 9 1 0 1 5 9 9- 1 7 4 4

SEWER NARRATIVE
LELAND COMMERCIAL
SEWER DESCRIPTION
The proposed Leland Commercial Project consists of 5 commercial outparcels and 123
townhome units. The project is located along HWY 17, south of Leland. This project will have
a sanitary sewer lift station that will be owned and maintained by the Town of Leland. The total
length of gravity pipe is 4,113 If of 8" C900 PVC & DIP. There will be 1,531 if of 4" force main
for the project. The flow for each townhome was assumed to be 210 gallon/unit and the flow
for the commercial lots was assumed to be 880 gallons/acre.

State of North Carolina
I �) Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Dlvlslon of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number:
(to be completed by D W R)
All items must be completed or the application Will be returned
L APPLICANT INFORMATION:
1. Applicant's name: Town of Leland (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: David Hollis per 15A NCAC 02T .0106(b)
Title: Town Manager
4. Applicant's mailing address: 102 Town Hall Drive
City: Leland State: NC Zip: 28451
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
❑ Privately -Owned Public Utility
❑ Other
I. Project name: Leland Commercial
2. Application/Project status: ❑ Proposed (New Permit) ® Existing Penmit(Project
If a modification, provide the existing permit number: W00040599 and issued (late: March 8. 2019
If new construction but part of a master plan, provide the existing permit number: W000_
3. County where project is located: Brunswick County
4. Approximate Coordinates (Decimal Degrees): Latitude: 34_.20. Longitude: -78 0707'
5. Parcel ID (if applicable): 04600040, 04600041. 0460004601, 0460046 & 046LA061
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Mark N. Hargrove License Number: 19742
Firm: Port City Consulting Engineers, PLLC
Mailing address: 6216 Stonebridge Road
City: Wilnringohr State: NC Zip: 28409-_
Phone number: [phone] Entail Address: nthargroveaec.rr.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Nante: Northeast Brturswick Regional W WTF Permit Number: NC 0086819
Owner Name: Brunswick County
V. RECEIVING DOWNSTREAM SEINER INFORMATION (if different than WWTF):
I. Permit Number(s): W00040624 Downstream (Receiving) Sewer Size: 10 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS_
Owner Name(s): Town of Leland
FORM: FTA 04-16 Page I of 5

VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
[]Yes ❑No NN/A
2. if the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ❑No NN/A
3. If the Applicant is a Home/Property Owners' Association has an Operational Agreement (FORM HOA) been attached?
❑ Yes ❑No NN/A
4. Origin of wastewater: (check all that apply):
N Residential Owned ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential Leased ❑ Retail with food preparation/service ❑ Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool /Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
N Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater : 100 % Domestic/Commercial _% Commercial
_ % Industrial (See 15A NCAC 02T .0103(20))
L-----*Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Has a flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes N No
➢ If yes, provide a copv of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f)
Daily Design Flow °'r'
No. of Units
Flow
Townhome Units
210 gal/unit
123
25,830 GPD
Commercial Property (Use not know)
880 gal/acre
7.76
6,829 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
32,659 GPD
a See 15A NCAC 021.0114(b). (dl. (e)(I) and (e)(21 for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use
areas; and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals
as defined in G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design Row rates fa establishments not identified [in table 15A NCAC 02T.01141 shall
be determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
S. Wastewater generated by project: 32569 GPD (per 15A NCAC 02T .0114)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, indicate why:
❑ Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit Number:
❑ Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other (Explain): _
FORM: FTA 04-16 Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8 4,113 C900 PVC & DIP
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirement is not allowed and a violation of the MDC
Vlll. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: 1
2. Approximate Coordinates (Decimal Degrees): Latitude: 34_20' Longitude:-78_07'
3. Design flow of the pump station: 0.088 millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 61 gallons per minute at 42 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
4
1,531
C900 PVC & DIP
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
® Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(h)(1)(B)
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility
Or if the pump station has an average daily flow less than 15,000 gallons per day:
❑ Portable power source with manual activation, quick -connection receptacle and telemetry - 15A NCAC 02T
.0305(h)(1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(h)(1)(C):
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations'
storage capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall he
provided in the case of a multiple station power outage.
FORM: FTA 04-16 Page 3 of 5

IX. SETBACKS & SEPARATIONS —(02B .0200 & 15A NCAC 02T .0305(0):
I. Does the project comply with all separations found in 15A NCAC 02T .0305(f) & (a)
➢ 15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewers stems:
® Yes ❑ No
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
24 inches
Water mains (vertical -water over sewer including in benched trenches)
18 inches
Water mains (horizontal)
10 feet
Reclaimed water lines vertical - reclaimed over sewer)
18 inches
Reclaimed water lines horizontal - reclaimed over sewer
2 feet
**Any private or public water supply source, including any wells, WS-I water of Class I or
Class II impounded reservoirs used as a source of drinking water
100 feet
**Waters classified WS (except WS-1 or WS-V), B, SA, ORW, HQW, or SB from normal
high water or tide elevation and wetlands (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
Any building foundation
5 feet
Any basement
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade vertical
36 inches
15A NCAC 02T.0305(¢) contains alternatives where separations in 02T.0305(f) cannot be achieved.
D **Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
If noncompliance with 02T.0305(f) or (e). see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ® Yes ❑ No
➢ See the Division's draft separation requirements for situations where separation cannot be meet
➢ No variance is required if the alternative design criteria specified is utilized in design and construction
As built documents should reference the location of areas effected
3. Does the project comply with all setbacks found in the river basin rules per ISA NCAC 02B .0200? ® Yes ❑ No
This would include Trout Buffered Streams per 15A NCAC 2B.0202
4. Does the project comply with an individual 404 Permit or any 401 Certifications? ® Yes ❑ No
➢ Wetland -related permits shall be requested, obtained, and adhered to for projects that impact wetlands or surface waters
➢ Information can be obtained from the 401 & Buffer Permitting Branch
5. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes ❑ No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications are being prepared, have
been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion and
sedimentation control plans, stornmvater management plans, etc.).
6. Does this project include any sewer collection lines that are deemed "high -priority?"
Per 15A NCAC 02T.0402, "high -priority sewer' means `any aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑ Yes ® No
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permitee's individual System -Wide Collection permit.
FORM: FTA 04-16 Page 4 of 5

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
If No, complete and submit the Variance/Alternative Design Request application (VADC 10.14) and supporting documents
for review. Approval of the request is required prior to submittal of the Fast Track Application and supporting
documents.
2. Professional Engineer's Certification:
I Mark N. Hargrove, PE attest that this application for
(Professional Engineer's name from Application Item III.1.)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans, specifications,
engineering calculations, and all other supporting documentation to the best of my knowledge. I further attest that to the best
of my knowledge the proposed design has been prepared in accordance with the applicable regulations, Gravity Sewer
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track
Permitting of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain
portions of this submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this
material and have judged it to be consistent with the proposed design.
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.
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
that this application for
& title from Application Item 1.3.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of
this application are not completed and that if all required supporting documentation and attachments are not included, this
application package is subject to being returned as incomplete. I understand that any discharge of wastewater from this non -
discharge system to surface waters or the land will result in an immediate 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.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly [Hakes 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: `+ YA �a..1 -- _ _ _ Date:
FORM: FTA 04-16 Page 5 of 5

D€vts1011 of Seater Resources
Entity Requesting Allocation: Town of Leland
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Project Name for which flow is being requested: Ibis Landing
More than one FTSE may be required for a single project if the owner of lite WWTP Is not responsible for all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
I
C.
d.
e.
WWTP Facility Name: Northeast Brunswick Regional W WTF
WWTP Facility Permit #: WQ 0086819
All flows are in MGD
WWTP facility's permitted flow 2.475
Estimated obligated flow not yet tributary to the WWTP
WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
1.19
2.116
0.032659
3.338
134.87%
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A) (B) (C) (D)=(B+C) (E)=(A-D)
Design Obligated,
Pump Pump Average Approx. Not Yet Total Current
Station Station Firm Daily Flow** Current Tributary Flow Plus
(Name or Permit Capacity, * (Firm / pfl, Avg. Daily Daily Flow, Obligated Available
Number) No. MGD MGD Flow, MGD MGD Flow Capacity***
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped flow
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor
(pf) not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer):
Downstream Permit Number:
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I Wm. L. Pinnix, P.E. (Eng. Director) certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
Official Signature
Title of Signing Official
E . �14/ZfZT%
Page 2 of 6
FTSE 10-18

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking fm• Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Town of Leland
Project Name for which flow is being requested: Ibis Landing
More than one FTSE mttr be required for a single project if the owner of the WIVTP is trot responsible for all pump
stations along the roue of the proposer/ wasteirater flow.
1. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name:
b. WWTP Facility Permit #:
Allflows are in NICD
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
Pump
Pump
Station
Station
(Name or
Permit
Number)
No.
(A)
Design
Average
Daily
Firm Flow"
Capacity, * (Firm / pf),
MGD MGD
Ibis 0.133
33 WQ0040624 2.28
10
0.033
0.911
1.613 0.645
(B)
(C)
(D)=(B+C)
(E)=(A-D)
Approx.
Obligated,
Current
Not Yet
Total Current
Avg. Daily
Tributary
Flow Plus
Flow,
Daily Flow,
Obligated
Available
MGD
MGD
Flow
Capacity***
0
0.033
0.033
0
0.071
0.071
0.84
0.390
0.397
0.787
-0.142
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped flow
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor
(pi) not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pwop station located
between the project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): Town of Leland
Downstream Permit Number: WQCS00333
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I David A. Hollis, PE certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the
receiving wastewater treatment facility and that the flow from this project is not anticipated to cause any
capacity related sanitary sewer overflows or overburden any downstream pump station en route to the
receiving treatment plant under normal circumstances, given the implementation of the planned
improvements identified in the planning assessment where applicable. This analysis has been performed
in accordance with local established policies and procedures using the best available data. This
certification applies to those items listed above in Sections I and II plus all attached planning assessment
addendunts for which I am the responsible party. Signature of this form certifies that the receiving
collection system or treatment works has adequate capacity to transport and treat the proposed new
wastewater.
Signing Offtcinl
mac nS &LA I�-4LAa� arz
Title q.fSigningOfficial
Page 2 of 6
FTSE 10-18

PLANNING ASSESSMENT ADDENDUM (PAA)
Submit a planning assessment addendum for each pump station listed in Section 11 where Available Capacity is <
0.
Pump Station (Name or Number): LS ID
Given that:
a. The proportion and amount of Obligated, Not Yet Tributary Daily Flow (C) accounts for
62 % and 0.397 MGD of the Available Capacity (E) in Pump Station
LS 10 ; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately
0.042 AVE MGD per year; and that
c. A funded Capital Project that will provide the required planned capacity, namely
N/A is in design or under construction with
planned completion in N/A ; and/or
d. The following applies:
The design ADF of 0.645 MGD with the current ADF of 0.390 resulting in an available wet
capacity of 0.255 with the annual project rate of activation of 0.042 MGD. It is expected
that the average rate of activation the LS 10 would reach capacity in 6 years. The Town
will monitor available capacity and provide capacity as needed with cooperation of
Brunswick County to increase the capacity in the common FM discharging to NorthEast
Brunswick Regional WRF coupled with upgrades to LS #14.
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow
this flow to be permitted, without a significant likelihood of over -allocating capacity in the system
infrastructure.
l understand that this does not relieve the collection system owner from complying with G.S. 143-
215.67(a) which prohibits the introduction of any waste in excess of the capacity of the waste disposal
system.
Signing Official Signature
Zb 2z)
Page 3 of 6
FTSE 10-18

DWR
Division of Water Resources
1. EXISTING PF.RM(TTEE INFORMATION:
State of North Carolina
Department of Environmental Quality
Division of Water Resources
SEWER SYSTEM PERMIT O iNERSHIP/NAME CHANGE
INSTRUCTIONS FOR FORM: PNOCF 01-16
I. Permittee's name: Brunwick Renional Wa(cr S Sewer I12GO
2. Signature authority's name: Bobo W gobWalker per L5ANC'AC 02T .0106(b) \
3. Signature authority's title: Director
4. Pennitlee's mailing address: P.O. Box 2230
City: Leland State: NC Zip: 2 451.2230
5. Penuittee's cou(act information: phone cumber: (212) 33 1-9L49 Fax Number (910) M-6441
Email Address: bwatker662goonline com
11. APPLICANT INFORMATION:
1. Applicant's name: Town of Leland
2. Signature authority's name: David Hollis per 15A NCAC 02T .0106(b)
3. Signature authority's title: Town Manager
4. Applicant's mailing address: 102 Town Hall Drive
City: Lcland State: NC Zip: 28451-_
5. Applicant's contact information: Phone number: (910) 71-1249 Fax Number (_)
Email Address: dhollis/r4townotlelatrd.com
6. Representative's name: Mark N. Hargrove. PE - Port City Consulting Eegincers PLLC
7. Representative's title: Engineer
8. Representative's contact information Phone number: [phone] Fax Number
Email Address: mhar rg [e-mail]
III. PERMIT INFORMATION:
1. Existing permit number: W00040599 and most recent issuance date: March 8. l99 a -al
2. Reason for the permit application: Change of Otwtership If other, attach detailed explanation
3. Has the facility been constructed? ❑ Yes or ® No
4. Has the facility been certified per 15A NCAC 02T .0116? ❑ Yes or ® No
FORM: PNOCF01-I6 Page I of

IV. CERTIlei CATIONS:
Existing Permittee's Certificatimt per 15A NCAC 02T.0106(b):
I, Bob Walker - Director Brunswick Regional Water & Sewer H2GO attest that this application
(Signature Authority's name & title from Application Item 1.2 & 3)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that prior to reissuance of (he
permit into the Applicant's name, I will continue to be responsible for compliance with the current permit and any discharge of
wastewater from this system to surface waters or (he land may result in an enforcement action that may include civil penaities,
injunctive relief, and/or criminal prosecution. twill also stake no claim against (he Division of Water Resources should a condition of
the existing permit be violated. I also underslantl that if all required parts of this application me note completed and that if all required
supporting information and attachments are not included, this application will be returned to ore as incomplete.
NOTE — In accordance with General Statutes 143-215 6A and 143-215 613, any person who knowingly makes any false statement,
representation, or certificotion 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 5,000 per violation.
Signature :)/='�Gi Dale: 1p _ j ate_ zU
Applicant's Certification per 15A NCAC 02T .0106(b):
David Hollis - Town Manager attest that this application
(Signature Authority's name & title from Application Item 11.20.)
has been reviewed by me and is accurate and complete to the best of my knowledge. 1 understand that after issuance of the permit into
the Applicant's name, I will be responsible for compliance with the issued permit and any 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 package arc not completed and that if all required supporting
information and attachments are not included, this application package will be returned to me as incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 143-215 6B, any person who knowingly makes any false statement,
representation, of certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,00`0�as well as civil(ppe-nnaa�lue up to $ 5,,000,0 pe • violation.
Signature: 1 10[ ,e.�— J / -✓ Dale: e j;?o
FORM: PNOCF 01-16 Page 2 of 2