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Home My WebLink AboutWQ0021622_Application_20200807State of North Carolina DWR Department of Environmental Quality Division of Water Resources Dlvlslon of Water Resources NON -DISCHARGE PERMIT OWNERSHIP/NAME CHANCE 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 wehsite A. Non -Discharge Permit Ownership/Name Change (FORM: NDPONC 06-16) Application (Ail 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), the Applicant shall demonstrate they are the owner of all roe 15A NCAC 02U .0201(e) or 15A NCAC 02U .0202(f), property rty 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 ISA NCAC 02T .Ol 15(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): Y Home/Property Owners' Associations ❑ Per 15A NCAC 02T .01 15(c), submit an original properly executed Operational Agreement (FORM: HOA). ❑ Per 15A NCAC 02T .01 15(c), submit an original proposed or approved Articles of Incorporation, Declarations and By- laws. Y 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 Q! In 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 '.VON -DISCHARGE BRANCH By U.S. Postal Service: 1617 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-1617 By Courier/Special Delivery: 512 N. SALISBURY ST. RALEIGH, NORTH CAROLINA 27604 TELEPHONE NUMBER: (919) 707-3654 1 U1 i u» � ir.0 LlID%4 VIIW i �,,. �c c_ rrinnnD'rIA1f: r f11'T1XA1:XTTATInXT page l of I I. EXISTING PERMITTEE INFORMATION: I . Permittee's name: ( Q ��( `(q ;t,e S ZC Z e 5,,.-0 2. Signature authority's name: per 15A NCAC 02T .0106(b) Title: 3. Permittee's mailing address: �r Gee "1�� .Irooll City:y State: Arc 7- 4. Permittee's contact information: Phone number:9710 Email Address: S ?c zus C 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 [JIT<0 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 ❑Q No d. is non -compliant with an existing non -discharge permit, settlement agreement or order? ❑❑❑ Yes or 00 o e. Has unpaid annual fees in accordance with 15A NCAC 02T .0105(c)(2)? ❑❑❑ yes or ❑ 10 II. FACILITY INFORMATION: 1. Facility name: 3�Nel', fC3St'_ -5F Iz 2. Facility's physical address: 3C) 1t-i+cqc_ Ur. City: epj State: NL Zip: County: to I�uYti III. PERMIT INFORMATION: 1. Existing permit number: WQ00Y(o,� and most recent issuance date: �1►g 2. Existing permit type: Select 3. Reason for the permit application: Select 4. Has the facility been constructed? ❑❑/Yes or ❑❑ No IV. APPLICANT INFORMATION: ' I 1. Applicant's name: JC—FF 2. Signature authority's name: per 15A NCAC 02T .0106(b) Title: 3. Applicant's mailing address: _220 Ran W�f U2 City: A(IEX State: ME, Zip: L12Z 3 1 4. Applicant's contact information: Phone number: (9) ZS -_7j Email Address: UosSrv�arla?iPN�b�On�n�. �� 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 ❑9No b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑❑❑ Yes or ❑[7f No c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑❑❑ Yes or ❑Ef No d. Is non -compliant with an existing non -discharge permit, settlement agreement or order? ❑❑❑ Yes or ❑gNo c. Has unpaid annual fees in accordance with 15A NCAC 02T .0105(e)(2)? ❑❑❑ Yes or ❑gNo Existing Permittee's Certification per 15A NCAC 02T .0106(b): attest that this application for (Signature Authority's name & title from Application Item 1.2.) _' n �tyr tc'C C. SPR (Facility namblrom Application Item II.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 143-215.613, 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): I, (Signature Authority' ame & title from Application Item IV.2.) _3311 H r,wt , - s- (Facility name frm Application Item I1,1.) that this application for 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 143-215.613, 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 Zaas civil1�2 penalties up to $25,000 per violation. Signature: / `— �/ Date: 1��Cv��O State of North Carolina Department of Environment and Natural Resources Division of Water Resources DWR 15A NCAC 02T .0600—SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEMS OPERATION AND MAINTENANCE AGREEMENT FORM: SFRWWIS O&M 08-13 Division of Water Resources Pennit No. A oo m n County: a)a.+ om Property owner(s) as appearing on the recorded deed: ' eTT- oni Lajmq L RUM Mailing address: 3N t1&i -a&e ! N(, 4-15,23 Facility address: 395cl Rell w Dr. 4g )JL Irrigation Method: ❑ SPRAY X DRIP I / We agree to operate and maintain the single-family residence wastewater treatment and irrigation system as follows: 1. The Petmittee is responsible for the operation and maintenance of the entire wastewater treatment and irrigation system including, but not limited to, the following items: a. The septic tank shall be checked annually and pumped out as needed. b. The septic tank effluent filter shall be checked and cleaned annually. c. Accessible sand filter surfaces shall be raked and leveled every six months and any vegetative growth shall be removed manually. d. ❑ The tablet chlorinator shall be checked weekly. Wastewater grade tablets (calcium hypochlorite) shall be added as needed to provide proper chlorination (pool chlorine tablets shall not be used), OR AThe ultraviolet disinfection unit shall be checked weekly. The lamp(s) and quartz sleeve(s) shall be cleaned or replaced as needed to ensure proper disinfection. e. All pump and alarm systems shall be inspected monthly. f. The irrigation system shall be inspected monthly to ensure that the system is free of leaks, that all irrigation equipment is operating as designed, that vegetative growth does not interfere with the system inspection or operation, that the soil is assimilating the disposed treated wastewater with no visible runoff or ponding, and that no objectionable odors are being generated. 2. Failure to pay the annual fee shall be cause for the Division to revoke the permit pursuant to 15A NCAC 02T .0105(e)(3). 3. The Permittee's failure to properly operate this system is subject to a penalty up to $25,000 per day. 4. Failure to meet the pen -nit conditions or violation of the State's surface water or groundwater regulations may void the permit. All owners appearing on the legally recorded property (Iced shall sign this Operation & Maintenance Agreement I / We understand the above requirem and agree to these terns as part of the issued pennit. Owner Signature: Date: e,1(40 Owner Signature: Date: FORM: SFRWWIS O&M 08-13 Page i of 1