WQ0023422_Application_20201103

state cif ;North Carolina
DWR
Department of Fni iron)r)ental Quillity
iiii, ision of eA ater resources
Division of Water ResourcesNON-DIS( t[:AWit, PERMIT t)1l Ni:ltSlllP� tN'E "I %N(;F
INS'I RI (, I € I)NS 1-01t 9 ()RNI: N I)pON( 06-16 & St 1`1*0111 IN6 IMC"(Nw.'s r V I ION
This furor is far ossnershiitchanges or name changes ref a non-dlsc'hAt'ge:)stem permit. Please :tote Ghat "Permittee"
referene" the existing permit holder, and that "Applicant" refereucos the enlilk appl%ing for the (rsvrter%hip.name ch;'"Te.
i' or moot' Rilor^rniituttl, t'rsrr tirr, Water �)tialal J't rnruttr¢� 5r r Fr ,r8 c orrrH F)rde ha)'g;t' 1 c rrgt€tasg�. I iPir s:• t,-;r,
A. Non -Discharge Permit OvknershipTNatnc ("harige (FOR'M; Ni)Pd)%C 06-16; Applicatinp I All Applicatt€tnsP'.
NC
❑ Submit an original Completed and jpprseg u atekt v-,vc to Npia pc:rn€t (), nor:hip Nritiw ('hjttt;e 4 i f R Mt NiilxO
110-1(1) application.
❑ Tito Existing Perinitice's C er(rlicutiun Nhtill be .tgncd to :dco€d.,ncc '.itit I 1 N( 1t t I fil,ta€,th,� Per 1 �. Nt� (.s�-
.til(1(4c), an alternate Person may he designitcal as the wigrlmg oti-octal it'a tletc��at€un [otter k Pro*,tt9csi tsorrs a F+srson mho
mecca the erttcrt€t in ea'�`
❑ The Applieant•SC'crtifitiationshallha;sib,necfin,tccordance%kith14,t�t tC.-fi��__€iltla,fh;.IbcciSt'�t_�C,. f Rriti6ytc�.in
alternate person may be designated a% the .is tie€rg oii1'Ci.tl if a cfcicgaaion jet;er as pro-, rded %Toni a per, on as ho nwc: the crit n
in 15A fit AC 021 (11 dhilh).
R. Existing Permit (All Applications):
❑ Submit a copy of the most recent I) issued pennit.
C. Property O%riership Documentation (All Applications):
Per 1SA NCAC t)3T fi5(-M—b. I5A NC', (' ()a-i .66i1�, I �A•4 !CAC 02T t 7i33 � l Sa r :i�[ s)' 4 .0 (€ 8, k mN(. C i
101 W[c)), 15A NCAC 02T .I 3(tS dl' , tS.n C'AC' lf'_ 1 .l ii€d . i I \C X( �21'-IY.01Lc) ar I ��1„�{ ���C" 021' tirif�"�i1.
the Applicant shall demonstrate they are the owner of all pmperty containing the non-diwhargc s)sicin facilities:
❑ Legal documentation ofownmhip (i.e., CiIS. deed or article of incorporation), or
❑ Written notarized intent to purchase agreement signed by both parties with a plat or cun'ey map. or
❑ Written notarized lease agreement that specifically indicates the intended use ofthe property and has item sip
r[ed 6y boot
parties, as well as a plat or survey map. Lease agreeincnts shall adhere to the requirements Of 1.?A NCA(
D. Cerliffcate of public Convenience and Necessity (All Applicafiotis where the Applicant is a privately -Owned Public Utility):
❑ Per I5A ' CAC: 02T .Ol l5fa l , provide one copy of the Certificate of Public C.'onveninict= and Necessity from the North
C'arohna Utilities Comtniss;on demonstrating the Applicant is authorized to hold the utilit% frarichisc for the area to be served
by the non -discharge system.
E. Operational Agreements (All Applications where the Applicant is a llome'Property Owners' Association or Dc%cloper of lore to
be sold):
i NomeTro erty Owners' Associations
❑ Per 15A NCAC 02T .(11 151c )• submit an original properly executed Qg7�Lraional A:rcecinc it `0RM: 110.11.
❑ Per I SA NC'AC 027' .()I I Sic), submit an original proposed or approved Articles of Incorporation, Declarations and By-
laws.
i Developers of lots to he m>ld.
© Per 15A XCAC 02T JI I.I5{l) • submit :an original cif the property cceQuied (�crgtional �'��rcemCfit (�()�Ni,m --
F. Operation and Nfainteriance Agreement (Fill Applications for Single-family Wastessater Irrigation Systems):
❑ Per 027 submit an original of a notarized 0 Oration and Maintenance Agreement FOR'et: SFR1t \VlS
OBhi) that has been signed and dated by all deeded property owner,.
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL OF SUBMITTED TO:
NORTH CAROLI?! A DEPARTMENT OF ENVIRONMENTILL QUALITY
DI't'ISION OF WATER RESOURCES
WATER QUALITY PF,it6ll'I'"I ENG SECTION
NON-DISC'IIARGE PERMITTING UNIT
By US. postal Service: By Courier/Special Delivery:
Non -Discharge Branch Non -Discharge Branch Archdale 942W 8 Email:
1617 Mail Sen ice Center 512 N. Salisbury St. i9nn-Discharr c.Re aoTtafw 'dcnr. cos
Raleigh. NC 27699-1617 Raleigh, NC27604
Telephone Number: [phone]
INSTRUCTION'S FOP FORM: NDPONC 06-16 8 SUPPORTINCj DOCUMENTATION Page I of l

0
State of North Carolina
[Department of F;nvironmental Quality
DWR Division of N'ater Resources
NO'*'-IlISC;HF1Rt:k. PF R,%I1T C71VNi°=RSH1P?1A. T E CHANGI
Division of Water Resources E't)itvi: -C 06
1. EXISTING PERMITTF.E INFORMATION:
Permittee's name: Robert C. —and Jamic_L,.. Kindbcrt�--.....---- .......
_ .-
Signature authority's name: per NC,,XC� 021.0;ta6 Title:2. ��.... ---•—
- -,
3. Permittee's mailing address:
Stara:
City: f3'e'et5vlLc
4. Permiltce's contact inf lunation: Phone number: i qlq } G �'
u5"<3i� Email Addrrl;s:
S. Demonstration of historical consideration for permit approval - I SA Y At 0ZA _0112fl:
Ilas the Permiltcc or auy parent. subsidiary or other affiliate exhibited the following?
a. Has been convicted of environmental crimes under Federal law or GAS [�i?-? 1 jh�i? � Yes or ]o
VC
b. bias previously abandoned a w�astatsater treatment facility without property closing that facility? ®Yes or ilJ �o
C. Ha$ unpaid civil penalty Where alt appeals have been abandoned or exhausted'.' 0 Yes or E(No
d, is non -compliant with an existing non -discharge permit, settlement agreement or order? 0 Yes or
Yes or No
e. Has unpaid annual fees in accordance %vith .1 Sri �iCr�L" 0�l .(tit) e1
r
11. FACILITY INFORMATION:
1. Facility name: J 4 t
2. Facility"s physical address:
State: �Gip: 't7713 - County: Chatham
City:
III. PEP -MIT INFORMATIOIo:
1. Existing permit number: WQ00 23422 and most recent issuance date: t r2du2 it7
2. Existing permit type: Single -Family Residence Wastewater Irrigation
3. Reason for the permit application: Changc of Ownersllip
4. Has the facility been constructed? QYcs or 0 No
IV. APPLICANT ITFORYIATION:
1. Applicant's name:
2. Signature authority's name:
per 1-5 n hC�'lC 02"f .O106 b Title: _.............._�—
3. Applicant's mailing address:
����ha-•-,am —�---
State: N! Lip:,7ti-
City:
4. Applicant's contact information: Phone number:
Email Addres,:
5. Remonstration of historical consideration for permit approval - 15A N(,kC 02.T .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. 143-2I i 6B`? 0 Yes or 0 No
b. Has previously abandoned a wastewater treatment facility without properly closing that facility? [3 Yes or Q lvo
c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? C] Yes or 0 No
d. Is non -compliant with an existing non -discharge permit, settlement agrecment or ordcr? 0 Yes or 0 No
e. Has unpaid annual fees in accordance with 15A NCAC 02T.0l OS e 3�7 ❑ Yes or [I No
Page I of 2
FORM: NDPONIC 06-16

Existing Permittee's Certification per 15 k > 'AC 11. I A106 h :
astte,,t that this applt.c3t0n for
(Signature Authorut,'� nartte & t;tle from Application (tent 1.2,1
-- t Facility name front Application Iteltt II.1:3
of the permit
has been reviewed by the and is accurate and complete to the best of nay kttoy ledge. I understand that prior to reissuattce
into the Applicant's name, any discharge of• svastc-1c�r from this ncrn-discltarge sy tcm to urfaec a>nery or the land will re%tzlt in an
enforcement action that may include civil pcnaiticx, sniunctavc relict•, and:or criminal prowcutton. t wilt make ns clat[n agaimt the
Division ofWater r Resources should a condition of the existing permit be violated. I also understand that if all rc.luttz;d part' of this
application package are not completed and that irall required supporting information and attacltt�tcnFs are rat included. this application
package will he returned as incomplete. I further certify that the existing l'+muttei or nny ar(itiate ha nras bicn can;icticl of an
ern ironmcntal crime. has not abandoned a w•utitc,sater facility ev ithout proper closure, does not hat a an Ljolhtanding civil penalty alter
are compliant with any active compliance schedule, and do not have anv overdue annual
all appeals have been exhausted or abandoned,
tees per l5:A N \C Q21.0J-0i(c1.
;NOTE - 1n accordance with General Sttautes I-I?--'-1-5 6 \ and 143-21 LB. any person %%ho kno%%ingh make+ an; false stai,ement,
include a fine not torepresentation, or certification in any application package shall be guilty of C1as, 2 misdemeanor, whichtnsy
exceed Slo.()oo as veil as civil penalties up to 525JM per violation.
Signature:
t.7`%,�G Date. !Ci -:�✓
Applicant's Certification per I Lk ti£ A(' OZT .0106t b :
that this application for
(Signature Authority's name & title from Application Item IV.Z.)
(Facility name from Application Item II.I .)
has been revic wcd by me and is accurate and complete to the best of my knowledge. I understand that after reissuance of tite permit
into the Applicant's name, any, dischartic 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. ) 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 hm e
been exhausted or abandoned. arc compliant with any active compliance scheduic, and do not have any overdue annual fees per I%.
NC'AC
NOTE - In accordance with Clencral Statutes 14,3_2I4.6A and I43 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 SI0.0©0 as well as civil penalties up to $25,000 per violation.
/ Date: 1 :.j1Q Ltd
Signature: ie-—
FORJM: NDPONC 06-16 Page 2 of 2