WQ0005790_Application_20210225

DWR
Dlvlslon of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 01-20
This form is for renewal without modification far all nnn-discharge system permits, exic!e Residuals NUnngement and Singh
Family Reildence Wastewater Irrigation System permits.
For more infortnaltron, visil the Water Quality Permitting Section's !Von -Discharge Branch ll'e tune_
1. PERMITTEE INFORMATION:
I. Permittee: Tawas of Oak Island
2. Signature authority's name: David E_ Kelly per l5A 1LICAC b2T . lC6(blTitle: Town Manager
Primary Telephone number: 9( n 20 1 -8002 Select Secondary number' (910) .�L2-4912 �e� ,I=
Email Address: DKe11y(d,.6.aak-island.nc.us
3. Permittee's roiling address: 4601 E. Oak Island Drive
City: Oak Island Statt: NC Zip: 28465-521 .
4. Billing address (if different from above): Same
City: - State: zip:
5. Contact person's name (if different from signature authority): Mark Moore Title: Public Works Director
Primary Telephone number: (9I b) 617-1242 Select Secondary cumber- (4I Q) 278- M 11 aftj=
Email Address: ) Maure(@ci.osk-island.nc.us>
11. PERMIT PGORMATION:
1. Existirig perrtrit n-umber: WQ00057YU
2. Has the facility been constructed? [K Yes pr ❑ No
If yes, has the facility been constructed in accordance with the permit and the ]division -approved plans and specifications?
[ 15A_NCAC 02T .01 I0] 0 Yes or ❑ No
If na, a formal permit modification request shall be submitted to the Division.
a. Has any of the property ownership within the Facility an&br disposal area changed from what is indicated in the current
permit (Attachment B - disposal field owner/lessee)? ❑ Yes or Z No
Has the Permittce had a name change or has the permit changed avntership? ❑ Yea or ® No
If yes to either, a permit modification request shall be submitted to the Division. [ 15A NCAC 02T .01051
4. Is this facility a Privately -Owned Public Utility? ❑ Yes or [DNo
If yes, provide two copies of the Certificate of Public Copvenience and Necessity From the North Carolina Utilities
Camn&,5ion demonstrating the Applicant is authorized to hold the utility franchise. [15AJ!CAC 02T {}1 l5(a){1}l
5. Is the Permittee a HomelProperiy Owners' Associations or Developers of lots to be sold? ❑ Yes or ®No
If yes, provide the following:
* For Horne/Froperty Owners' Associations - Operational Aacement (FORM: HOA} and a copy of the proposed or
approved Articles of Incorporation, Declarations, and By -Saws [1.5A K.AC 027=01 INO
a For Developers of lots to be sold - 00crationaI Agreement ll:ORM: DIE [U& 11 A-C02T .0115(h]j
FORM: NDSi,01-20 Page 1 of

DWR
Dlvlslon of Water Resources
6. Does the facility treat and dispose of industrial wastewater? No
If yes, complete items below. If no, skip to the next section.
Indicate the approximate percentage of wastewater rnaketip;
Industrial: °Io Domestic: �% 5tormwater: !%
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 4I-20
For all industrial wastewater sources (excluding those permitted under a pretreatment permit), pfovide a detailed industrial
process description including:
• An overview of the manufacturing process
• An inventory of all materials used for manufacture, including chemicals and biological "natter
• An overview of cleaning and treatment methodology, including an inventory of tmattmcnt 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 applicar on(s) changed? ❑ Yes or ❑ No
If yes, a permit modification request sha[1 be submitted to the Divisicn. TG.S. 141-215.1
III. SITE MAP:
I. Provide an updated site map in accordance with 1.5A NCAC 02T .0105(dl that shows the following (if applicable):
The site map is not required to be signed ar sealed by a Professional Engineer. However, the map must indicate the source of
information. For example, parcel lines taken from a county GI5 map should reference the GIS website.
0 Legend, north arrow, and scale
0 Topographic contours on all disposal sites
0 Soil mapping units on alI disposal sites
IR All facility -related structures and fences within the treatment, storage, and disposal areas
El All habitable residences and places of assembly within 500 feet of MI 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 diisposai site(s)
(D Latitude and longitude co-ordinates of ull monitoring wells (decimal degrees to 6 digits)
• Location and identification of major components of the waste disposal system
• The wetted perimeter cf at irrigation fields with fie]d names (named according to the approved permit)
ICI Location and ownership of property boundaries within 500 feet of the disposal area {including roadlraiI right-of-ways)
❑ The delineation of compliance and review boundaries
® Distance measurements verifying all setbacks are being met
❑ Swrmwater drainage controls
® 100-year floodplain
❑ For reglaimM water generatica permits, provide a separate rasp showing all distribution lines and utilizatiort 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.
F011K NDSR 01-2) Page 2 of

DWR
Division of Water Resources
IV. GROUNDWATER MONITORING WELLS
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RtNI ,WAL
FORM: NDSR 01-20
I. Does the facility have a proposed or existing groundwater manitaring wel3 network? 0 Yes or ❑ No
If no, skip to next section.
If yes, complete the following table (NOTE — This table may be expanded Far additional wells):
Well Name
Status
Latitude'
Longitude a
Gradient
Location
2
seject
39.8388660
-85.8680360
Dawn -Gradient
aftki
5
stita
39.836748"
-85.8677140
Down -Gradient
Select
6
agi=
39.838401"
-85,868347"
Daum -Gradient
Select
7
el 2 ct
39.8390150
-85,864440"
Cross -Gradient
select
Select
°
-
Select
Select
Select
-
Select
Select
Select
b
-
Select
anl��t
Select
Select
elect
elect
-
Select
Select
Select
- 8
Select
selcct
a. Coordinates must be in NAD83 and have 6 decimal degTees
V. SETBACK WAIVERS, EASEMENTS, AND LEASES:
1. Does the permit have any .setback waivers, easements, or leases? ❑ Yes ar 0 No
If yes, provide copies of all documents and complete the table below:
Document
Type
Grantor or
Parcel Teo.
Granee
t
Expiration
Date
County
Registered
Deed
Book
Deed Fags
Dbcurnent
Description a
Select
Select
elect
ele t
select
elect
Selee
a. The document description shall list any reduced sethacks with distance, etc,
2. For reclaimed water utilization permits.
Is reclaimed water utilized on property ii�l controlled by the geneeamry ❑ Yes or ® No
A lease, easement, or agreernernt must be provided allowing for the utilization of reclaimed water on the property or within
the Facility. For irrigation of reclaimed wager, an easement is required per 15A NCAC 02U .05C 1(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, NPDFS, etc.), complete the table below
(provide additional pages if necessary):
Permit T e
Permit No.
Description
COLLECTION
WQ0003790
2. Does the facility have an approved flow reduction [15A NCAC 02T .0114M? ❑ 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 Fermittee 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 I5A NC AC 02T A106(b}
I, _ David E. Ke11y , 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 enfc=er=1 action that may include civil penalties, injunctive relief, andlar criminal proseention, 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 143-2 l5_CA 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 S10,000 as well as civil penalties up to $25,000 per violation. The Applicant's Certification shall be signed in accordance with
L5A1'i 1�-02T .0L06(h . Per l5A NCAC 02T .OI06(c) an alternate person may be designated as the signing official ifa delegation
letter is prN,,, from a pef en who meets the criteria in 15A NCAC 02T ,O 106[b}
Signature:
Date: z Lzc?.,
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED TO:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
ICON -DISCHARGE BRANCH
By U.S. Postal Service: By Courier: By Email:
Non -Discharge Branch Non -Discharge Branch - A-rchdale 942W NQn :DischargeRcpoirts(eencdenr.goy
1617 Mail Service Center 512 N. Salisbury St.
Raleigh, NC 27699-1617 Raleigh, NC 27604
TELEPHONE NUMBER, [phone]
)FORM: NDSR 01-20 Page 4 nf4