WQCS00257_Renewal (Application)_20210112

RECEIVED
JAN 12 2021
November 27, 2020 NCDEQ/DwR/NPDES
NCDEQ-DWR
Attn: PERCS Unit Supervisor
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Collection System Permit Renewal
Maury Sanitary Land District
Maury Sanitary Land District Collection System
WQCS00257
Greene County
Dear PERCS Unit:
The Maury Land Sanitary Land District holds permit#WQCS00257 for the operation and maintenance of
the sewer collection system. The permit expiration date is May 31, 2021. The District is submitting a
permit renewal application package. The renewal package includes one original and one copy of:
- Cover letter
- Completed Application Form CSA 04-16
- Pump station list
- High priority lines list
- Annual Budget for Collection System (current fiscal year)
- Capital Improvement Plan
- Response action plan
- Contingency Plan
- Sewer collection map
If you any questions, please call Jim Kuipers: 252/341-3980.
Sincerely,
Lawrence Moye, Jr., Chairman
Maury Sanitary Land District

L APPLICANT INFORMATION:
1. Applicant's name(Municipality,Public Utility,etc):Maury Sanitary Land District
2. Facility Information Name: Maury Sanitary Land District Collection System Permit No.:WQCS00257
3. Applicant type: ❑Municipal ❑ State ❑Privately-Owned Public Utility
❑ County ®Other: Sanitary Land District
4. Signature authority's name:Lawrence Moye.Jr. per 15A NCAC 02T.0106(b)
Title: Chairman
5. Applicant's mailing address:PO Box 98
City: Maury State:NC Zip: 28554-0098
6. Applicant's contact information:
Phone number. [phone] Fax number.[phone] Email address: NA
II. CONTACT/CONSULTANT INFORMATION:
1. Contact Name:Jim Kuipers
2. Title/Affiliation:Director,Maury Sanitary Land District
3. Contact's mailing address:PO Box 98
4. City: Maury State:NC Zip: 28554-0098
5. Contact's information:
Phone number [phone] Fax number: [phone] Email address: NA
III. GENERAL REQUIREMENTS:
1. New Permit or Premit Renewal? ❑New ®Renewal
2. County System is located in: Greene County
3. Owner&Name of Wastewater Treatment Facility(ies)receiving wastewater from this collection system:
Owner(s)&Name(s):Maury Sanitary Land District
4. WWTF Permit Number(s): NC0061492
5. What is the wastewater type? 100%Domestic or %Industrial(See 15A NCAC 02T.0103(20))
Is there a Pretreatment Program in effect?❑Yes or®No
6. Wastewater flow:0.110 MGD(Current average flow of wastewater generated by collection system)
7. Combined permitted flow of all treatment plants: 0.225 MGD
8. Explain how the wastewater flow was determined: ❑ 15A NCAC 02T.0114 or®Representative Data
9. Population served by the collection system: 800
IV. COLLECTION SYSTEM INFORMATION:
1. Line Lengths for Collection System:
Sewer Line Description Length
Gravity Sewer 4.8(miles)
Force Main 2.5(miles)
Vacuum Sewer NA(miles)
Pressure Sewer NA(miles)
APPLICATION CSA 04-16 Page 3 of 5

2. Pump Stations for Collection System:
Pump Station Type Number
Simplex Pump Stations(Serving Single Building) NA
Simplex Pump Stations(Serving Multiple Buildings) NA
Duplex Pump Stations 2
3. Submit a list of all major(i.e.not simplex pump station serving a single family home)pump stations. Include the following
information:
➢ Pump Station Name
➢ Physical Location
➢ Alarm Type(i.e.audible,visual,telemetry,SCADA)
➢ Pump Reliability(Can convey peak hourly wastewater flow with largest single pump out of service)
D. Reliability Source(permanent/portable generator,portable pumps)
➢ Capacity of Station(Pump Station Capacity in GPM)
4. Submit a list of all high priority lines according per 15A NCAC 02T.0402(2)known to exist in the collection system. Head
the list with"Attachment A for Condition V(4)"and include the system name.
➢ Use the same line identification regularly used by the applicant
➢ Indicate type of high priority line(i.e.aerial),material and general location
V. COLLECTION SYSTEM ADMINISTRATION:
1. Provide a brief description of the organizational structure that is responsible for management, operation and maintenance of
the collection system.
Board—Director(ORC)
2. Indicate the current designated collection system operators for the collection system per 15A NCAC 08G.0201
Main ORC Name: Jim Kuipers Certification Number: 988209
Back-Up ORC Name: Joe Roberts Certification Number: 1004220
See the"WQCS Contacts and ORC Report"for a current listing of the ORC(s)the Division has on file for WQCS permit
3. Approximate annual budget for collection system only: $80,000.00
4. Submit a copy of your current annual budget.
5. Approximate capital improvement budget for the collection system only: $20,000.00
6. Submit a copy of your current capital improvement plan.
7. Is this collection system currently a satellite system❑ Yes or®No
8. Do any satellite systems discharge to this collection system❑Yes or®No(If yes complete table below)
Satellite System Contact Information(Name, Address,Phone Number)
Complete for Satellite Systems that have a flow or capacity greater than 200,000 GPD(Average daily flow)
9. List any agreements or ordinances currently in place to address flows from satellite systems:
NA
APPLICATION CSA 04-16 Page 4 of 5

VI. COLLECTION SYSTEM COMPLIANCE:
1. Is a Response Action Plan currently in place®Yes or❑No
2. If Yes,submit a copy of the Response Action Plan or see table 6 below.
3. Is a pump station contingency plan currently in place?®Yes or❑No
4. If Yes,submit a copy of the pump station contingency plan or see table 6 below.
5. Is a comprehensive collection system map currently in place? ®Yes or❑No
6. Submit a submit a copy of the collection system map(CD or hardcopy)or indicate a schedule for completion
7. Thoroughly read and review the System-Wide Collection Ssstem Permit Conditions. Typically compliance schedules
are only offered to NEW permit applicants and NOT permit renewals. Any compliance dates must be included within
the permit prior to issuance or the permit holder will be found in violation upon inspection.
If no,Indicate a Typical
Permit Condition Current Compliance Compliance
Compliance? Date Schedule
I(4)—Grease ordinance with legal authority to inspect/enforce ®Yes ❑ No 12— 18 mo.
I(5)— Grease inspection and enforcement program ® Yes ❑No 12— 18 mo.
I(6)—Three to five year current Capital Improvement Plan. ®Yes ❑No 12—18 mo.
I(8)—Pump station contingency plan N Yes ❑No 3 mo.
I(9)—Pump station identification signs. ®Yes ❑No 3 mo.
I(11)—Functional and conspicuous audible and visual alarms. ®Yes ❑No 3 —6 mo.
II(5)—Spare pumps for any station where one pump cannot
handle peak flows alone(in a duplex station,the 2"d pump is ®Yes ❑No 6—9 mo.
the spare if pump reliability is met).
II(7)—Accessible right-of-ways and easements. ®Yes ❑No 6— 12 mo.
II(9)—Response action plan with Items 9(a—h). ®Yes El No 3 mo.
III(3)—Comprehensive collection system map ® Yes ❑No 10%per year
For conditions not listed,compliance dates are not typically offered. List any permit conditions that may be difficult for the
applicant to meet(attach clarification if needed):
NA
VIL APPLICANT'S CERTIFICATION per 15A NCAC 02T.0106(b):
I,Lawrence A.Moye,Jr.,Chairman attest that this application for Maury Sanitary Land District
(Signature Authority's Name&Title from Item I.4) (Facility name from Item L1)
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 information and attachments are not included,this application package
will be returned to me as incomplete.
Note: In accordance with NC General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed
$10,000 as well as c' ilk,ties u to 25,000 pe violation.
Signature: Date: -- %( d
APPLICATION CSA 04-16 Page 5 of 5

Maury Sanitary Land District
Maury SLD Collection System
WQCS00257
Part IV.4
High Priority Lines
There are no High Priority Lines in the collection system.

Maury Sanitary Land District
Collection System Permit Renewal
Part IV - 3
WQCS00257
Pump Station List
Name Location Alarm Pump Reliability Reliability Source Capacity GPM
Lift Station#1 4250 Hwy 123 North (Snow Hill) Audible, Visual,Telemetry Yes Generator 400
Bypass Connection
Lift Station#2 Maury Ballpark Rd (at Hwy 903) Audible, Visual, Telemetry Yes Bypass Pumping 100

,
2019-2020 2020-2021
Acct Revenues:
601 Water and Sewer Charges $383,7 00.00
604 Interest on Investments 2,000.00 3��/'�Uci `%c,
608 Sample Fees 2,400.00 ego c a vo
601 Fees to Operate New Correction Unit 1 o - v
P 42.000.00 ` Z v�F,,-v
$430,100.00 ,t ja6,, $0.00
Expenditures:
921 Salaries 62,000.00 ‘G,Uu�"JL
923 Retirement 6.000.00 o L, ,
856 Contract Labor 35,000.00 ,3 a,a oc
906/851 Legal and Audit Fees 9,000.00 9,..r,c, v v
918 Office Supplies 3,500.00 j.S7..)U- c0
852 Advertisement 500.00 3 . v v
945 Board Expense 300.00 3 4:Ao
941 Telephone 6.700_00 G7c0 0 a
916 Miscellaneous Expense 3,500.00
911 Utilities36,000.00v "3�^�� �o
j eici c` c c
863 inspection/Sample Fees/Lab Fees 12,000.00
904 —Insurance 20.000.00 ,z..2,. c..x, _e v
903 Interest Expense 500.00 ,57D C.) ��
930 Repairs and Maintenance 60.000.00 619 0eV> v c.-;
922 Supplies 9,000.00U o d
943 Capital and Improvement-Drinking Water 6,000.00 a aid. c9G;
946 Capital and Improvement-Waste Water 20,000.00 erj`, D 0
947 Contingency 400.00
•fir;. "6
853 —gox Rent 300.00 36 e G`;
854 Bank Charges 700.00
887 Payroll Taxes 7.500.00 7uvf
879 Travel Expense 15.000.00 7S�G� v
l3/ U:
6.000.00
920 Fees &Permits , .
G�c c
931 Garbage Pick-up 6,200.00 0, e)0
935 Training 500.00 O`,�0
933 Annual Inspection/Maintenance 13,500.00 /3;"1G- 0 3
701 Purchase ofWater 53.000.00 `,da4_��
705 Water Meter Assessment Fees (Pd to County) 37..000.00 j7,..4„_,d
$430,100.00 1,..... 20 d $0.00
0 0

Maury Sanitary Land District
Pump Station Contingency Plan
WQ CS00257
The Maury Land Sanitary District operates and maintains two(2)duplex pump stations. In the case of
pump station failure,the following steps will be taken:
• Type of failure will be determined: Mechanical or Electrical
• Electrical Failure
➢ Pumps station#has an onsite generator
➢ Pump stations#1 and#2 have constructed bypass lines and a portable pump is available
for bypass pumping
➢ Spare parts—fuses, breakers, alternators,relays,etc—are available for the more common
failures.
➢ Electrical contractor will be called as needed.
• Mechanical Failure
➢ Pump will be inspected to check for blockages
➢ Control floats will be checked
➢ Bypass pumping connections are installed at all pump stations. The District has a
portable pump for bypass pumping.
• Pump Failure
➢ There is a spare pump for each pump station
➢ If pump cannot be made operational on-site:
• Pumps will be sent to pump/motor repair shop or pump repair company will be
contacted for on-site repair.
• If both pumps in the pump station fail or if the remaining pump cannot maintain the water level:
➢ A septage hauling company will be contacted to pump out the pump station wet well as
needed.
➢ Bypass pumps are available as needed.

Maury Sanitary Land District
Wastewater System
Capital Improvement Plan
FY 2020/2021 - FY 2022/2023
PURPOSE AND DEFINITIONS:
The purpose of the capital improvement plan (CIP)is to forecast and match projected revenues and major
capital needs over a five-year period. Capital planning is an important management tool that strengthens
the linkages between community infrastructure needs and the financial capacity of the MSLD.
The MSLD defines CIP capital expenditures as any expenditure of major value that recurs irregularly,
results in the acquisition of a fixed asset, and has a useful life greater than one (1) year. As a rule of
thumb, items included in the CIP include those which:
• Involve acquisition, renovation,and/or construction of a single fixed asset greater than $2,500.
• Involve any land purchases greater than $50,000 not associated with or included in another CIP
project.
The CIP is updated annually to ensure that it addresses new and changing priorities within the MSLD.
CAPITAL IMPROVEMENT PLAN DEVELOPMENT:
The CIP is updated annually as part of the MSLD's regular budget process. Projects are reviewed and
evaluated based on the Board of Directors' service desires,other MSLD infrastructure needs,the financial
capacity of the MSLD and the impact the projects will create on the MSLD's operating budget.
Once the projects are evaluated, a recommended CIP is developed that identifies the selection and timing
of capital projects into future fiscal years. First-year projects are incorporated into the MSLD Director's
recommended annual operating budget. The Board are also presented the future, unappropriated planning
years for their consideration, review and endorsement so staff can proceed with planning and evaluation
of potential capital projects.
CAPITAL IMPROVEMENT PLAN:
The capital improvement plan is simply that— a plan. As such, projects are subject to change based on
new or shifting service needs, special financing opportunities, emergency needs, or other directives or
priorities established by the Board. Because priorities can change, projects included in outward planning
years are not guaranteed for funding.
The Maury Sanitary Land District's CIP achieves five major objectives as a component of the MSLD's
budget and financial planning process:
1. Helps the MSLD rationally and intelligently plan for the repair, replacement, and acquisition
of capital items that are necessary in providing high quality services to the citizens of
Maysville.
2. Assists in fiscal planning by forecasting capital demands together with future revenues and
expenditures (as part of the financial plan).
3. Insuring better coordination,evaluation,and planning of projects to serve the community and
its' needs.
4. The CIP,together with the Financial Plan, serves as a guide to decision-making for the Board,
MSLD Manager,and employees.

5. The systematic and comprehensive analysis of capital needs increases the probability of
making rational (and correct) budgetary judgments since improvements are identified,
prioritized,and matched to the projected fiscal resources of the MSLD.
Wastewater System:
The Maury Sanitary Land District operates a wastewater collection and treatment system that
serves approximately 830 customers. The majority wastewater contributor is the State of North
Carolina prison. The collection system is composed of approximately 38,000 linear feet of pipe
in various sizes of gravity sewer and force mains. There are two pump stations in operation. The
District's Wastewater Treatment Plant utilizes the activated sludge process with direct discharge
to the Contentnea Creek. The treatment plant is currently permitted to discharge up to 0.225
million gallons per day. The average daily flow at the treatment plant is 0.110 million gallons per
day.
CIP Projects — Collection System
Pump Station Control Panel—Replacement of Pump Station control panel.

Capital Improvement Plan (CIP) Summary
Project Primary Capital FY FY FY
Funding Cost 20-21 21-22 22-23
Source
PS Control Panel Operating 15,000 0 0 0
Revenue
Operating $15,000 $0 $0„„ $0
TOTAL Revenue

Response Actionpi 4
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: Maury
System Name Sanitary Land District
Permit Number: WQCS00257
Address:
PO Box 98
City/State/Zip: Maury, NC 28554
252/341-3980
Phone Number:
Fax: [phone]

CONTENTS
SECTION
I. Purpose
II. Objectives
III. Procedures
A. Receipt of Information Regarding a Sanitary Sewer Overflow
B. Dispatch of Sewer Maintenance Personnel to Site of Sewer
Overflow
C. Overflow Correction, Containment, and Clean Up
D. Overflow Report
E. Customer Satisfaction
IV. SSO Response Plan Maintenance
V. Appendices
Appendix A — Contacts
Appendix B — Spill/SSO Reporting Form

I. Purpose
This Response Action Plan has been prepared in accordance with Permit
WQCS00257 Part II (9) Operation & Maintenance Requirements. The purpose
of this Response Action Plan is to ensure proper sanitary sewer overflow (SSO)
reporting and minimize the adverse effects that may be caused by a Sanitary Sewer
Overflow.
This plan was revised on November 2020
This plan will be reviewed and/or updated annually to incorporate any changes in
contact information; system components; and/or personnel.
II. Objectives
The objectives of this plan are:
➢ To protect the public health and the environment
➢ To meet regulatory and permit requirements
➢ To develop and implement procedures to mitigate the effects of an SSO
➢ To protect the collection system and wastewater treatment personnel
➢ To ensure the longevity of the collection system and wastewater treatment
plant equipment
➢ To protect both public and private property
➢ To minimize regulatory enforcement and/or penalties, resulting from a
spill/S SO
➢ To provide appropriate customer service

III. Procedures
A. Receipt of Information Regarding a Sanitary Sewer Overflow
Sanitary Sewer Overflow's may be recognized and reported by system personnel or
by others. The System is responsible to act, in a timely manner, to all reports of a
possible SSO. Reports may be received via telephone, email, or by other means.
1. Typically reports received from the public will be received at Town Hall. Personnel
collecting information regarding a possible SSO, please obtain the following:
a. Time and date call was received
b. Specific location
c. Description of problem
d. Time possible overflow was noticed
e. Reporter's name and phone number
f. Observations of the reporter
g. Relevant information that will enable system personnel to quickly locate,
assess and stop the overflow
2. Appropriate system personnel will be notified when a possible spill is reported. All
reports of a SSO must be investigated by staff within two hours. System personnel
must confirm the spill before it will be considered an SSO. Only after confirmation
by system personnel will a spill be considered an SSO.
3. As soon as possible, but no later than 24 hours of the confirmation of a reportable
Sanitary Sewer Overflow, the NC DWR Washington Regional Office will be
notified according to the rules of NC Division of Water Resources. The rule is:
Sanitary Sewer Overflow (S SO) Reporting Requirements to the Division of
Water Resources
The Permittee shall verbally report to a Division of Water Resources staff
member at the appropriate Regional Office, as soon as possible, but in no case
more than 24 hours following first knowledge of the occurrence of either of the
following:
• Any SSO and/or spill over 1,000 gallons to the ground; or
• Any SSO and/or spill, regardless of volume, that reaches surface water
Voice mail messages or faxed information shall not be considered as the initial
verbal report. SSOs (and other types of spills) occurring outside normal business
hours may also be reported to the Division of Emergency Management at
telephone number [phone] or [phone].

4. Spills that are fully contained and removed quickly and are less than one thousand
gallons that do not reach surface waters are not required to be reported to NC DWR.
However, a full spill report form will be filled out and kept on file.
B. Dispatch of Sewer Maintenance Personnel to Site of Sewer Overflow
Confirmation of a Spill / Sanitary Sewer Overflow will activate an immediate
response to isolate and correct the problem. Personnel and equipment shall be
available to respond to any and all SSO locations.
1. Dispatching Personnel Instructions
➢ When a spill/SSO is received by the system, Staff and equipment shall be
dispatched to isolate and correct the problem in a timely manner
➢ Staff will be dispatched by telephone or radio
➢ Dispatching personnel must verify that all notified staff have received the
message
2. Maintenance Personnel Instructions
➢ All dispatched staff should proceed immediately to the site of the spill/SSO.
Any delays and/or conflicts should be promptly reported to the manager
➢ Upon arrival at the site of the spill/SSO, staff will report any and all findings
to the appropriate supervisor. These findings should include damage to both
public and private property
3. Supervisor Instructions
➢ The Supervisor will dispatch additional personnel, supplies, and equipment as
needed or requested by dispatched staff
➢ The Supervisor will update the Public Works Director and/or Town Manager
on a continuing basis if the SSO and/or repairs are not easily abated and fixed.
4. Initial Damage Assessment
➢ All dispatched staff must use discretionary action when responding to a
spill/SSO. Dispatched personnel must be aware that the System may be
responsible and/or liable for further damage to private property
➢ Dispatched personnel should not enter private property without authorization
from the Supervisor

➢ In order to thoroughly document the affected area, the dispatched staff will
take appropriate photos and/or video. Any photos and/or video will be
retained and filed with the spill/SSO report
5. Supervision and Inspection
➢ The Supervisor will ensure that the guidelines outlined in this SSO Response
Plan are properly implemented
➢ The Supervisor is responsible for properly notifying NC DWR Fayatteville
Regional Office within the amount of time specified within the reporting
requirement
➢ The Supervisor will coordinate with the Town Manager for the availability of
funds.
C. Spill/SSO Correction, Containment, and Clean-up
The objectives of the actions taken by system personnel are:
➢ To protect public health, the environment, and property from a spill/SSO
➢ To restore the surrounding area/property back to normal as quickly as possible
➢ To establish an appropriate perimeter to contain the spill/SSO, using
equipment (traffic cones, barricades), existing infrastructure (fencing, etc.),
and/or natural boundaries (berm, ditch, stream, etc.)
➢ To notify the appropriate regulatory agencies within permitted timeframe
➢ To protect surface water from contamination
➢ To minimize regulatory enforcement and/or penalties, resulting from a
spill/S SO
1. Upon arrival at a spill/SSO, the dispatched system staff will perform the following:
➢ Determine the cause of the spill/SSO (collection line blockage, lift station
malfunction, line break, etc.).
➢ Report findings to Supervisor and identify or request additional personnel and
equipment to minimize the effects of the spill/SSO.
➢ Should it be determined the cause of the spill/SSO is not the responsibility of
the system, dispatched personnel will;
o Take appropriate action to protect public health, property (public and
private), and surface water bodies from immediate danger.

2. Containment of a spill/SSO will be of utmost priority and will include, but are not
limited to, the following measures:
➢ Determine the immediate destination of the spill/SSO (storm drain, water
body, ditch, etc.)
➢ Identify and request the necessary personnel and equipment to contain and
minimize the effects of the spill/SSO
➢ Take the appropriate, immediate action to contain the spill/SSO
3. Additional measures may be necessary to contain a prolonged spill/SSO. These
measures will be determined and implemented by the Supervisor.
4. Clean up of a spill/S SO will be prompt and thorough. The necessary measures will
be taken to eliminate any identifiable evidence of the spill/SSO.
➢ If possible, photos will be taken before and after clean up. Photos will be filed
with the spill/S SO report
➢ The affected area will be cleaned of any sewage and debris. All materials
collected will be properly disposed of
➢ The area will be secured to prevent public contact, until the affected area has
been thoroughly cleaned
➢ The spill/SSO site should be disinfected and deodorized, if appropriate
➢ If spill/SSO has affected a surface water body, the NC DWR Washington
Regional Office will be contacted for specific instructions.
D. Overflow Reporting
A written report to the NC DWR Washington Regional Office is required within five
days. The Supervisor will complete the required reports and submit them to the NC
DWR Washington Regional Office. Additional reporting requirements to the public
may be required based upon volume discharged.

For accurate reporting purposes, system personnel should gather the following
information:
➢ Determine if the spill/SSO has affected any surface water bodies
➢ Estimate the start time of the of the spill/SSO:
o Date/time reported and confirmed by system personnel
o Visual observations
➢ Estimate the stop time of the spill/SSO:
o Date/time the blockage or equipment malfunction has been corrected
o Date/time system personnel arrived onsite, if spill/SSO stopped before
system personnel arrived
➢ Visual Observations
o Estimate the flow rate of the spill/SSO
o Estimate the volume of the spill/SSO
o Take photos for documentation
o Assess damage to public and private property (System personnel will
not enter private property to assess damage, unless authorized by the
Supervisor)
E. Customer Satisfaction
To ensure good public relations and customer satisfaction, the appropriate system
personnel will follow up with the reporting party. This follow up will include either
a personal visit or telephone call. The Supervisor will determine the information to
be disclosed to the reporting party.

IV. SORP Maintenance
This Sanitary Sewer Overflow Response Plan will reviewed annually.
Amendments may include:
> Changes in procedure
> Changes in contact personnel
➢ Changes due to regulatory requirements
V. Appendices
Appendix A — Contact Phone Numbers
Appendix B — Equipment List and Spare Parts Inventory

Appendix A
CONTACTS
Fmmemosainowneramenaleammememmeseni
Division of Emergency Management
800-858-0368
.
Contact / Affiliation Phone Email!
Jim Kuipers/Director MSLD ' 252/341-3980[
252/916-5063
Vann Johnson/Electrician
1-- . 252/824-7688 .
919/734-4267
Jerry Pearson/Pearson Pump Co
Cell: 919/580-5507
Cell: 919/422-8155
Freddie Hudson/Godwin Pumps
910/383-1106
Julian Jones/MSLD , 252/341-3981
Joe Roberts/Snow Hill Public Works Director I 252/939-5213
Tyndall Lewis/McDavid Engineering ' 919/736-7630
Washington Regional Office 252/946-6481
The Standard/Newspaper 252/747-3883
i
Hardy Construction—Edwin Hardy : 252/560-8539 ,
Hardy Construction— Sammy Hardy 252/560-2806
. i
1
[ :

Appendix B
Equipment List and
Materials
Location and Materials
Public Works Bid.
6' Portable Pump
Discharge Hose/Suction Hose
Barricades, Signs, Cones
Pipe
Pipe Fittings/Repair Clamps
Hand Tools
Gravel Pile
PS Electrical Parts
PS Spare Pumps

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State of North Carolina
DW
Department of Environmental Quality R
Division of Water Resources
15A NCAC 02T.0400—SYSTEM-WIDE WASTERWATER COLLECTION SYSTEMS
Division of Water Resources INSTRUCTIONS FOR FORM CSA 04-16&SUPPORTING DOCUMENTATION
Documents shall be prepared in accordance with 15A NCAC 02T .0100, 15A NCAC 02T .0400, and all relevant
Division Policies. Failure to submit all required items will necessitate additional processing and review time.
For more information, visit the System-wide Collection System Permitting website:
General—When submitting an application to the Pretreatment,Emergency Response,&Collection Systems(PERCS)Unit,
please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of requested
additional information.
The Applicant shall submit one original and one copy of the application and supporting documentation.
A. Cover Letter
• Submit a cover letter listing all items and attachments included in the permit application package
B. No Application Fee Required
➢ No application fee is necessary. The permittee will be billed an annual fee upon issuance of the permit
➢ The appropriate annual fee for systemwide wastewater collection system permits may be found at:
➢ Annual Non-Discharge Fees
C. System-Wide Wastewater Collection System (FORM: CSA 04-16)Application:
® Submit the completed and appropriately executed System-wide Wastewater Collection System (FORM: CSA 04-
16) application. Any unauthorized content changes to this form shall result in the application package being
returned. If necessary for clarity or due to space restrictions, attachments to the application may be made, as long
as the attachments are numbered to correspond to the section and item to which they refer.
❑ If the Applicant Type in Section I.3 is a Privately-Owned Public Utility, provide the Certificate of Public
Convenience and Necessity(CPCN)from the North Carolina Utilities Commission demonstrating the Applicant is
authorized to hold the utility franchise for the area to be served by the wastewater collection system,or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an
application for a franchise has been received and that the service area is contiguous to an existing franchised area
or that franchise approval is expected.
❑ If the Applicant Type in Section 1.3 is a corporation or company, provide documentation if it is registered for
business with the North Carolina Secretary of State.
D. General Information:
➢ The Authorized signing official listed in Section I.4 should match with that of the Applicant certification page 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).
• NOTE - Public Works Director's are not authorized to sign this permit application according to the rule
unless they are delegated.
INSTRUCTIONS FOR APPLICATION CSA 04-16&SUPPORTING DOCUMENTATION Page 1 of 5

E. Summary of Attachments Required:
• Instruction A: Cover Letter
® Instruction C: Application
❑ Instruction C: Ownership Documentation (i.e. CPCN) (If necessary)
❑ Instruction D: Delegation Letter(If necessary for signing official)
® Section IV.3 Pump Station List
® Section IV.4 High Priority Lines List
® Section V.4 Annual Budget for Collection System (Updated and Approved)
® Section V.6 Capital Improvement Plan (Updated and Approved)
® Section VI. 2 Response Action Plan
El Section VI.4 Contingency Plan
El Section VI.6 Comprehensive Collection System Map
O Section VII Note Any Potential Compliance Issues
THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS,SHOULD BE SENT TO:
NCDEQ-DWR
Water Quality Permitting Section
PERCS UNIT
By U.S.Postal Service: By Courier/Special Delivery:
Attn: PERCS Unit Supervisor 512 N. SALISBURY ST.Suite 925
1617 MAIL SERVICE CENTER RALEIGH,NORTH CAROLINA 27604
RALEIGH,NORTH CAROLINA 27699-1617
TELEPHONE NUMBER: [phone]
INSTRUCTIONS FOR APPLICATION CSA 04-16&SUPPORTING DOCUMENTATION Page 2 of 5