WQ0020493_Application_20201123

State of North Carolina
DWR
Division of Water Resources
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 01-20
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 Website.
I. PERMITTEE INFORMATION:
1. Permittee: ?A972 /CvHR�Lob U/oZW6 r'i4C1LlT
2. Signature authority's name: FNR►'r/.a^fl PAtT,y per 15A NCAC 02T .0106(b) Title: CO il1,s5/9c`'
Primary Telephone number: (020) 962-A7 Secondary number: ( )
Email Address: >C�.4Q?O� G l'A1P7aJ! wA13TX , foM
Permitteee's mailing address: ,,157 ?4&,Pn/
City: 15u?N6XftrR>7Tpr✓ State
4. Billing address (if different from above):
City: State: Zip:
Al.G Zip:;&)3S -
5. Contact person's name (if different from signature authority): DA)'I'j EVAi✓5 Title:AV�lGX7/1e_ 64ery�l6R
Primary Telephone number: 1L11$7- L1257 Secondary number: (M7Sj' 6p2�
Email Address: d e-vta,ms 'C.,PA('omuMberL.CoM
II. PERMIT INFORMATION:
1. Existing permit number: WQ00 � D y93
2. Has the facility been constructed? Z Yes or ❑ No
If yes, has the facility been constructed in accordance with the permit and the Division -approved plans and specifications?
[ 15A NCAC 02T .01101 XJ 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 fZ 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 P<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 NCAC 02T .0115(a)(1)1
5. Is the Permittee a Home/Property Owners' Associations or Developers of lots to be sold? ❑ Yes or A) No
If yes, provide the following:
• For Home/Property Owners' Associations — Operational Agreement (FORM: HOA) and a copy of the proposed or
approved Articles of Incorporation, Declarations, and By-laws [15A NCAC 02T .0I 15(c)]
• For Developers of lots to be sold — Operational Agreement (FORM: DEV) [I 5A NCAC 02T .0115(b)]
FORM: NDSR 0 1 -20 Page 1 of 4

State of North Carolina
DWR
Division of Water Resources
6. Does the facility treat and dispose of industrial wastewater?
If yes, complete items below. If no, skip to the next section.
Indicate the approximate percentage of wastewater makeup:
Industrial: % Domestic: % Stormwater: %
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 01-20
For all industrial wastewater sources (excluding those permitted under a pretreatment permit), 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
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. IG.S. 141-215.1(d)1
III. SITE MAP:
1. Provide an updated site map in accordance with 15A NCAC 02T .0105(d) that shows the following (if applicable):
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 GIS map should reference the GIS website.
J' Legend, north arrow, and scale
❑ Topographic contours on all disposal sites
❑ Soil mapping units on all disposal sites
Q' 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
0' 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 with field names (named according to the approved permit)
g ' 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
2"' 100-year floodplain
❑ For reclaimed water generation permits, 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 01-20 Page 2 of 4

DWR
Division of Water Resources
IV. GROUNDWATER MONITORING WELLS
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 01-20
1. Does the facility have a proposed or existing groundwater monitoring well network? ❑ Yes or 4 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 a
Longitude a
Gradient
Location
Select
0-0
Select
Select
Select
0-0
Select
Select
Select
0-0
Select
Select
Select
0-0
Select
Select
Select
0-0
Select
Select
Select
0-0
Select
Select
Select
0-0
Select
Select
Select
0-0
Select
Select
Select
0-0
Select
Select
Select
0-0
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 U No
If yes, provide copies of all documents and complete the table below:
Document
Type
Grantor or
Parcel No.
Grantee
Expiration
Date
County
Registered
Deed
Book
Deed Page
Document
Description
Select
Select
Select
Select
Select
Select
Select
a. The document description shall list any reduced setbacks with distance, etc.
2. For reclaimed water utilization permits:
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 02U .0501(6). All documents shall be listed
in the table above.
FORM: NDSR 01-20 Page 3 of 4

DWR
Division of Water Resources
VI. RELATED PERMITS
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 01-20
1. If this permit has interactions with other wastewater permits (collection systems, NPDES, etc.), complete the table below
(provide additional pages if necessary):
Permit Type Permit No. Description
2. Does the facility have an approved flow reduction [15A NCAC 02T .0114(f) ? ❑ 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 CNot
TIFICATION 15A NCAC 02T .0106(b)
I, 7ZPvJ , attest that 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 to me 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 02T .0106(c), an alternate person may be designated as the signing official if a delegation
letter is provido4foiki a persona who me is the criteria in 15A NCAC 02T .0106(b)
Signature:
Date: %fiLA6
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 U.S. Postal Service: By Courier: By Email:
Non -Discharge Branch Non -Discharge Branch — Archdale 942W Non-Discharge.Reports(a�ncdenr.gov
1617 Mail Service Center 512 N. Salisbury St.
Raleigh, NC 27699-1617 Raleigh, NC 27604
TELEPHONE NUMBER: [phone]
FORM: NDSR 01-20 Page 4 of 4

11/9/2020
CONNECTGISWE6
Overview Map
Current Segment:
1.28 Feet
Last Segment:
5.27 Feet
Total:
4,314.58 Feet
Total Area:
293,073.42 Sq. Feet
or 6.73 Acres
or 0.01 Sq. Miles
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RUTHERFORD COUNTY
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WQ0020493
SITE LOCATION MAP
103 C,