WQ0039324_Sewer Extension Permit Status Update_20210624

Request for Engineering Certification Date of Letter: June 15,2021
Sewer Extension Permit Status Update
Please complete the applicable portion of this form for each permit and return this form and supporting documents by July 14,2021
to the attention of Collin Geersen at the Division's Municipal Permitting Unit by the delivery method below:
NCDEQ/DWR
WQPS—Municipal Permitting Unit
By U.S. Postal Service: By Courier/Special Delivery: By Email:
1617 Mail Service Center 512 N. Salisbury St.Suite 925 Collin Geersen
Raleigh, NC 27699-1617 Raleigh, NC 27604 [e-mail]
Permit No.:WQ0039324 Permittee: Town of Warsaw
Project Name: Warsaw Taco Bell Sewer
Project Status (Complete Signature& Date section below. Check appropriate box 'to indicate Permittee's response.)
Name&Title(priinnt))::� Scotty Summerlin, Town Manager '
Signature: c�UJ 7 Date: I[: —2z— i
Comments: None.
SEWER NOT YET CONSTRUCTED
❑ The Permittee certifies that the permitted project has not been constructed but shall be constructed in the future in conformity
with the approved Permit, project plans,specifications, and supporting documents.The Permittee understands that the
appropriate certification documents will need to be forwarded to the Division prior to operation. Subject permit shall be
maintained in Active status. NOTE: If sewer will never be built, please complete Permit Rescission Request section below.
SEWERE HAS BEEN CONSTRUCTED
® Engineer's Certification: The Permitted project has been constructed and the required Certification page and supporting
documents are being submitted to the Division with this form.
OWNERSHIP/NAME CHANGE
❑ The Permittee requests information to apply for ownership or name change. Please provide email and phone number below for
follow-up.
Permit Rescission Request
The Permittee requests that the subject permit be rescinded and certifies that the permitted sewer system has not been and shall
not be constructed nor made operational. Ry cignine below. we acknowledge that should we wish to operate a non-discharge sewer
system in the future, we shall apply for and receive a new Wastewater Collection System Permit.
Name&Title(Print):
Signature: Date:
Comments:
Contact Information Updates for Permittee
Updated Contact Person&Title(Print): Scotty Summerlin, Town Manager
Updated Mailing Address: P.O. Box 464, 121 S. Front St. , Warsaw, NC 28398
Updated Email: manager@townofwarsawnc Updated Phone: [phone] , ext . ji(
.com

ROY COOPER r=1 44,i
Governor M+
DIONNE DELLI-GATTI 4
Secretary
S.DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
June 15, 2021
Scotty Summerlin
Town of Warsaw
PO Box 464
Warsaw, NC 28398-0464
Subject: Engineering Certification Request
Town of Warsaw
Duplin County
1 Dear Permittee:
Based on a review of our records for permits issued during the period of 2016 through 2017, it appears that .
the Division of Water Resources(Division) has not yet received a final engineering certification in accordance
with 15A NCAC 02T.0116,as well as the standard conditions of the permit,for the Wastewater Collection
System Extension Permit(s) listed below.
• Permit No. WQ0039324:Warsaw Taco Bell Sewer issued on 7/27/2017
If the permitted facility,or any portion of the facility,has been constructed and is in operation,a complete
engineering certification is required to be submitted prior to placing the system into service. It should be
noted that failure to certify a sewer extension permit appropriately in accordance with the provisions of 15A
NCAC 02T.0116 may result in enforcement action.A complete certification is one that includes a copy of '
the construction record drawings(plan and profile views of all sewer lines), pump station design
calculations(if applicable), and the certification form as provided with the original permit. Please note
that the Division may not acknowledge the receipt of certifications, however,the status can be viewed
at any time using our online Sewer Extension Permit Tracker located on the Municipal Permitting Unit
website.
If the permitted facility has not been constructed and will not be constructed,the Permittee may request
to have the permit rescinded by returning the attached Status Update form. If the Permittee no longer
owns the facility or the Permittee's name has changed, please return the attached Status Update requesting
information for ownership/name change. Please note that Permits are not automatically transferable in the
event the project site is now owned by others.
1 The Division requests a response from the Permittee by July 14,2021.
The Status Update form on the back of this letter should be completed and included with all submittals.
If you have any questions regarding this outreach program,please contact Collin Geersen via e-mail at
[e-mail]. Alternatively,voice mail messages can be left at(919)707-3608.
Sincerely,
hri n L.-Fertenbau h P.E. Environmental Engineer
C sty g g
Municipal Permitting Unit, Division of Water Resources
cc�`CWilmington Regional Office, Water Quality Section Regional Operations[electronic]
Municipal Permitting Unit [electronic copy]
Q North Carolina Department of Environmental Quality Division of Water Resources
RT�D E
�/ 512 North Salisbury Street 1617 Mail Service Center I Raleigh,North Carolina 27699-1617
"+r � a+. / „ 919.7079000

PW-
State of North Carolina
Department of Environmental Quality
Applicant Certification Form
In accordance with 15A NCAC 18C .0303 (c), a signed applicant certification must be submitted
to the Department, stating that the Operation and Maintenance (O&M) Plan and the Emergency
Management Plan requirements have been satisfied and that the system will have a certified
operator as required by Section .1300. No construction, alteration, or expansion of a community
or non-transient, non-community public water system shall be placed into final service or made
available for human consumption until the applicant has submitted the certification and has
received Final Approval from the Department.
Certification must be provided by the following individual or their duly authorized representative:
1. For a corporation, limited liability company, home owner association or non-profit
organization: a president, vice president, secretary, or treasurer,
2. Fora partnership or sole proprietorship: by a general partner or the proprietor,
3. For a municipality, State, Federal or other agency: by either a principal executive
officer or ranking elected official.
By the signature below I certify, under penalty of law:
1. The following actions have been completed for the construction, alteration, or expansion of
the water system, as defined in the project documents:
• I, or personnel under my direct supervision, have completed an O&M Plan and an
Emergency Management Plan in accordance with 15A NCAC 18C .0307(d) and (e).
Based on my evaluation of the plans, or my inquiry of the person or persons directly
responsible for preparing the O&M Plan and Emergency Management Plan, the
information contained in the plans is, to the best of my knowledge and belief, true,
accurate, and complete.
11
2. The following actions will be completed before the construction, alteration, or expansion of
the water system, as defined in the project documents, is placed into final service or made
available for human consumption:
• In accordance with 15A NCAC 18C .0307(d), the O&M Plan will be made accessible
to the operator on duty at all times and available to the Department upon request.
• In accordance with 15A NCAC 18C .0307(e), the Emergency Management Plan will
be made accessible to the system operator on duty at all times and available to the
Department upon request.
• In accordance with 15A NCAC 18C .0303(c), the system will have a certified operator
as required by 15A NCAC 18 C. 1300.
Signature: Name(Print): Scotty Summerlin
Title: Town anager Date: April 23rd, 2021
Project Name: Taco Bell Water Extension System Name: Warsaw, Town of
Serial No: 17-00634 Water Sys. ID: 04-31-015
Certifications can be sent by mail, fax[phone]), or attachment to an e-mail message to
[e-mail]

T
TOWeOW \RSAW
Public Water System Project
Engineer Certification Form
By the signature below I certify:
The referenced public water system project was completed in substantial
compliance with the approved engineering plans and specifications,
including any provisions stipulated in the Department's plan approval
letter or authorization to construct letter, and revised only in accordance
with the provisions of Rule ,0306.
This is a
X Full certification
Partial certification, covering
This certification is based upon inspections conducted (select one):
X Daily
Continuously
Periodically
By (select one):
Myself
X* Another under my review
Seal here: ,�` N CA•RO �''';
. Fssio••.•'1.
SEAL
041609
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Engineer Signature: ( f f - Engineer Name(Print): Michael Thompson, PE
Project Name: Taco Bell I Warsaw Date: 05/04/2021
Serial No: 17-00634 Water System Name: Warsaw,Town of
Pictures provided by contractor and town supervisor personal supervision information only.
Certifications can be sent by mail,fax[phone]), or attachment to an e-mail message to
PWSSection.PlanReview@ncdenr•gov