WQ0004502_Renewal Application_20210113

Initial Review
INITIAL REVIEW
Reviewer
Thornburg, Nathaniel
Is this submittal an application?
(Excluding additional information.)*
r Yes r No
Is this a complete
application?*
Complete App Date
r Yes r No
01 /13/2021
Project Number*
WQ0004502
Applicant/Permittee
Hillsborough United Church of Christ
Applicant/Permittee
200 Davis Road, Hillsborough, NC 27278
Address
Is the owner in BIMS? Is the facility in BIMS?
r Yes r No r Yes r No
Owner Type Organization
Facility Name Hillsborough United Church of Christ WWTF
County Orange
Fee Category Fee Amount
Minor $0
Signature Authority
Signature Authority Title
Signature Authority Email
Document Type (if
non -application)
Email Notifications
Does this need review by the hydrogeologist?*
r Yes r No
Regional Office
CO Reviewer

Admin Reviewer
Below list any additional email address that need notification about a new project.
Email Address
Comments to be added to email notification
Comments for Kendall
Comments for RO
Comments for Reviewer
Comments for Applicant

Submitted Form
Project Contact Information
Rease provide information on the person to be contacted by MB Staff regarding electronic subnittal, confirmation of receipt, and other issues.
........................................................................................................................................................................................................................................................................................................................................................................
Name * Christy Gracia
Email Address*
[e-mail]
Project Information
Submittal Type* r New Permit Application
r Renewal
r Annual Report
r Other
Permit Type * r Wastewater Irrigation
r Other Wastewater
r Closed -Loop Recycle
r Single -Family Residence
Wastewater Irrigation
Is a paper copy of the application being submitted?
r Yes r Nor N/A
Permit Number* WQ0004502
Applicant\Permittee * Hillsborough United Church of Christ
Phone Number*
919-732-9183
Applicant/Permittee 200 Davis Road, Hillsborough, NC 27278
Address*
Facility Name * Hillsborough United Church of Christ WWTF
r Modification (Major or Minor)
r Additional Information
r Residual Annual Report
r High -Rate Infiltration
r Reclaimed Water
r Residuals
r Other
Please provide comments/notes on your current submittal below.
Please attach all information required or requested for this submittal to be review here.
Application Formt Engineering Rans, Specifications, Calculations, gc.)
Irrigation Water System Permit Application.pdf 311.78KB
Upload only 1 RJF document. NLltiple docurrents must be corrbined into one RJF file.

For new and modification permit applications, a paper copy may be required. If you have any questions
about what is required, please contactthe reviewer or Tessa Monday. If a paper --polka*-ion is required,
be advised, applications accepted' far pre -review until both the paper and eIect-c-,i_ co1)ies nave been
received. The paper copy shall include the following:
o Application Form
o All relevant attachments (calcs, soils report, specs, etc.)
o One full-size engineering plan set
o One 11x17" engineering plan set
o One extra set of specifications
o Fee (if required)
MallinE address:
❑iuision of Water Resources1 Division of Water Resources
Non -Discharge Branch I Non -Discharge Branch
1617 Mail Service Center 1 Aft: Nathaniel Thornburg, 91° Floor, Cfice #942W
----------------------------------------------------------- -----------------------------------------
Raleih, NC 27699-1617 512 N. Salisbury St.
Far questions or problems contact Tessa Monday [e-mail] or 919.707.3560.
* W By checking this box I acknowledge that I understand the application will not be accepted
for pre -review until the paper copy (if required) and fee (if required) have been received by
the Non -Discharge Branch. I also confirm that the uploaded document is a single PDF with
all parts of the application in correct order (as specified by the application).
Signature
Submission Date 1/13/2021

DWR..
Division of Water Resources
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, exceot Residuals Management and Single -
Family Residence Wastewater Irrigation System permits.
For more information, visit the Water Quality Permitting Section's Non-Dischar e Branch Website.
I. PERMITTEE INFORMATION:
I_ Permittee: Hillsborough United Church of Christ
2. Signature authority's name: Russell E. Knots per 15A NCAC 02T .0106(b)
Primary Telephone number: 9I9) 732-9183 Select Secondary number: (_) = Select
Email Address: [e-mail]
3. Permittee's mailing address: 200 Davis Road
City: HilIsboroutrh State: NC Zip: 27509-
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:
II. PERMIT INFORMATION:
1. Existing permit number: WQ0005402
2. Has the facility been constructed? ® Yes or ❑ No
Title:
If yes, has the facility been constructed in accordance with the permit and the Division -approved plans and specifications?
f 15A NCAC 02T .0I 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 Pennittee had a name change or has the permit changed ownership? El 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. f 15A NCAC 02T .0115(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 — Operational Agreement (FORM: HOA) and a copy of the proposed or
approved Articles of Incorporation, Declarations, and By-laws 15A NCAC 02T :0115(c)7
• For Developers of lots to be sold — .Operational Agree ent(FORM: DEV) f 15A NCAC 02T .0115(b)]
FORM: NDSR 05-20 Page 1 of 4

State of North Carolina
DWR....
Division of Water Resources
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
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 (c.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. FG. S. 143.-215.1(d)1
III. SITE MAP:
Provide an updated site map in accordance with 15A 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 GIS 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, intennittent, 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)
❑ 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

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 05-20
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 a
Longitude a
Gradient
Location
Select
0-C,Select
Select
Select
-
Select
Select
Select
0-0
Select
Select
Select
-0
Select
Select
Select
-
Select
Select
Select
-
Select
Select
Select
-
Select
Select
Select
-0
Select
Select
Select
°
-
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, casements, or leases? ❑ Yes or ® 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 a
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 only:
Is reclaimed water utilized on property not controlled by the generator? ❑ Yes or ❑ No
A lease, casement, 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 casement is required per 15A NCAC 02U .0501(6). All documents shall be listed
in the table above.
FORM: NDSR 05-20 Page 3 of 4

DW.R,.
Division of Water Resources
VI. RELATED PERMITS
State of North Carolina
]Department of Environmental Qjxality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 05-20
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 f 15A NCAC 02T .0114(il]? ❑ 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)
I,RuS 41 KnDpL, 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 provided from a person who meets the criteria in 15A NCAC 02T .4106(b)
Signature:
Date: _ j "` %
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:
httos://edocs.deq.nc.aov/Forms/NonDischarQe-Branch- Non-Discharge.Re orts nedenr. ov
Submittal -Form
TELEPHONE NUMBER: [phone]
FORM: NDSR 05-20 Page 4 of 4

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