WQ0021204_Application_20200820

Division of Water
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 05-20
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 111'ebsite.
I. PERMITTEE INFORMATION:
1. Permittee: North Chatham Volunteer Fire Department, Inc
2. Signature authority's name: Mark Rig sg bee per 15A NCAAC 02T .OI 06(b)
Primary Telephone number: [phone] Select Secondary number: [phone] Select
Email Address: [e-mail]
3. Permittee's mailing address: 45 Morris Road
City: Pittsboro State: NC Zip: 27312-
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:
11. PERMIT INFORMATION:
Title: Deputy Chief
1. Existing permit number: WQ0021204
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?
[I5ANCAC 02T_01 10.] ® 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 .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 NAC 02:T_01 1 S(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 — U.perationaleeinent EOIZM__H.OA) and a copy of the proposed or
approved Articles of Incorporation, Declarations, and By-laws [L. A:NCAC
• For Developers of lots to be sold— Qperatiollal Agreement _1 ORM_DI VJ [15A NCAC_021' .0115(b)]
FORM: NDSR 05-20 Page 1 of 4

State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
1 I t ion of i t t r Resources FORM: NDSR 05-20
6. Does the facility treat and dispose of industrial wastewater? If yes, complete items below. If no, skip to the next section.
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
Indicate the approximate percentage of wastewater makeup:
Industrial: % Domestic: % Stormwater: %
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.
Ill. SITE MAP:
1. Provide an updated site map in accordance with] 5A NCAC 02T__0105(d) 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 G1S 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)
❑ 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 witb 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 (if applicable)
❑ For reclaimed water generation permits only, 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 05-20 Page 2 of 4

State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 05-20
IV. GROUNDWATER MONITORING WELLS
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 "
Longitude "
Gradient
Location
Select
0-
Select
Select
Select
0-
Select
Select
Select
0-
Select
Select
Select
°
- °
Select
Select
Select
0-
Select
Select
Select
°
- °
Select
Select
Select
°
-
Select
Select
Select
°
- °
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. 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
Grantor or
Expiration
County
Deed
Document
Type
Parcel No.
Grantee
Date
Registered
Book
Deed Page
Description
Bynum &
North
Select
Juanita
Chatham
Chatham
918
1081
Agreement
Clegg
Vol. Fire
Dept.
Select
Select
Select
Select
Select
Select
a. The document description shall list any reduced setbacks with distance, etc.
2. For reclaimed water utilization permits only:
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,02_C.J 0501.(6). All documents shall be listed
in the table above.
FORM: NDSR 05-20 Page 3 of 4

V1. RELATED PERMITS
1. If this permit has interactions with other wastewater permits (collection systems, NPDES, etc.), complete the table below
(provide additional pages if necessary):
i
Permit Type Permit No. Description
2. Does the facility have an approved flow reduction [15A NCAC 02T .01 14-ffl]? ❑ 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)
Ina1,rk 41 - aArthat 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 tome 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 021' .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 1.5A NCAC 02'I' .0106(b)
Signature: ✓�(C� Date:'��
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 Upload By Email:
ht1ps_//edocs dW.i1p g_v/l_orms/No»l_�ischarL;�_ _Bi-aiich- Non_Discharge_Repoils ncdenr.gov
Submittal -Farm
TELEPHONE NUMBER: [phone]
FORM: NDSR 05-20 Page 4 of 4

%J-viG'�� dilu AW
002f 24
BOOK 91 a PAGE 10 81
STATE OF NORTH CAROLINA
AGREEMENT
COUNTY OF CHATHAM
THIS AGREEMENT, made and entered into thisib"-lday of 914i# 2002, by
and between D. BYNUM CLEGG and wife, JUANITA W. CLEGG, hereinafter referred to as
"CLEGG"; and NORTH CHATHAM VOLUNTEER FIRE DEPARTMENT, hereinafter
referred to as "NCVFD';
WITNESSETH:
WHEREAS, Clegg owns property conveyed by deed recorded in Book _, Page` of
the Chatham County Registry and NCVFD owns property conveyed by deed recorded in Book
855, Page 953 of the Chatham County Registry; and
WHEREAS, a proposed spray irrigation facility to be constructed by NCVFD lies
approximately 50 feet from its boundary with the County of Chatham and approximately 110
feet from the western boundary of Clegg as is more particularly described on the sketch attached
hereto as Exhibit A and incorporated herein by reference; and
WHEREAS, the State of North Carolina Administrative Code Regulation 15A NCAC
2H.02190)(5)(J)(i) requires a buffer zone of at least 150 feet for any such facility from any
property line; and
WHEREAS, the County of Chatham has waived the requirement of a buffer zone of 150
feet and has agreed to a buffer of 50 feet; and
WHEREAS, Clegg is willing to waive and relinquish their right to the buffer zone
provision afforded by said administrative regulation and desire to execute this agreement to
effectuate said waiver;
NOW, THEREFORE, for a valuable consideration; the undersigned do hereby waive the
provisions imposed by 15A NCAC 2H.02190)(5)(J)(i) insofar as it requires a buffer zone of 150
feet from the spray irrigation facility proposed by NCVFD to be located upon its property as set
forth on the sketch attached hereto as Exhibit A and incorporated herein by reference. Clegg also
releases NCVFD and the State of North Carolina, their agents and employees, from all liability
arising out of the siting or location of said facility as proposed including, without limitation,
negative or adverse impacts upon their property; provided, however, nothing contained herein
shall be deemed to release NCVFD from future liability arising out of the operation of said
facility in an manner not authorized by law.
•

BOOK 918 FAGS z U 8 2
IN WITNESS WHEREOF, the parties have hereunto set their hands and seals the day
and year first above written.
f-r' (SEAL)
D. BYWM
2'S ^" (SEAL)
ANITA W. CLEGG
NORTH CHATHAM VOLUNTEER FIRE DEPT.
By:
STATE OF NORTH CAROLINA
COUNTY OF CHATHAM
1, a Notary Public of the County and State aforesaid, certify that D. BYNUM CLEGG and
JUANITA W. CLEGG personally appeared before me this day and acknowl;dged.thece .ecution of
the foregoing instrument
2 _L Yof'
Witness my hand and official stamp, or seal, thi day j ; 5
My Commission Expires:
STATE OF NORTH CAROLINA
COUNTY OF CHATHAM
1, a Notary Public of the County and State aforesaid, certify that _�LQ ed�
on behalf of North Chathatn Volufittcer!Fire
Department personally appeared before me this day and acknowledged the gxution of the
foregoing instrument
'
Witness my hand and official stamp or seal, thi4 Atl. day of ` , 9102;,•-';.
My Commission Expires
Notary' Public'
NORTH CAROLINA. CHATHAM COUNTY
The foregoing Certificates) of Jennifer C. Bouldin Notary(les)
Public is (are) certified to be correct. This Instrument was presented for registration at 12:42 o'clock
.1,'. _• on February 27 �20`022 and rec rdedj_rvBook 918 page 1081
REBA 0, THOMA9, B, lrrQ q �) I"1[fYYlc �}
REGISTER OF DEEDS FOR CHATHAM COUNTY (No AwMIMt - Register of es
�xhih�i-(i wu� CL�i+ckotQ.
•

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DRAINAGE FLOW DIRECTION I NORTH CHATHAM VOLUNTEER FIRE DEPARTWN
SPRAY IRRIGATION SYSTEM
CHATHAM COUNTY
W 0021204/GW02054
SITE DETAIL MAP