The URL can be used to link to this page

Home My WebLink AboutWQ0000265_Information Received_20210810August 4, 2021 Division of Water Resources Non -Discharge Branch 1617 Mail Service Center Raleigh, North Carolina 27699-1617 To Whom It May Concern:. Subject: Permit No. WQ0000265 Signature Authority Designation Washington Correctional Center Wastewater Irrigation System Washington County As an appropriate signing official for North Carolina Department of Transportation (city/town or business name) as designated by 15A NCAC 2T .0106, I hereby delegate authority to sign and certify all permit applications, reports or other permit related documents to the following staff for the following permit types (sewer, spray, land application) and/or permit numbers: Position Person Currently in Position Permit Type or Permit Number David Heath Stallings Facilities Maintenance Engineer WO0000265 Steve Trowell Environmental Specialist II WO0000265 If you have any questions, please contact me at the following: Permittee/Applicant name (please print): North Carolina Department of Transportation C/O Ronnie L. Keeter Jr., PE Title: Chief Engineer Complete mailing address: 1536 Mail Service Center City: Raleigh State: NC Zip: 27699-1536 Telephone number: ( 919 ) 707-2500 Facsimile number:( 919 ) 733-9428 Since l• IY, si;aature DocuSign Envelope ID: C64F1ED7-1419-4E5A-A7A9-A2075E3CE0AB State of North Carolina DWR Department of Environmental Quality Division of Water Resources NON -DISCHARGE PERMIT OWNERSHIP/NAME CHANGE Division of Water Resources INSTRUCTIONS FOR FORM: NDPONC 06-16 & SUPPORTING DOCUMENTATION This form is for ownership changes or name changes of a non -discharge system permit. Please note that "Permittee" references the existing permit holder, and that "Applicant" references the entity applying for the ownership/name change. For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit website A. Non -Discharge Permit Ownership/Name Change (FORM: NDPONC 06-16) Application (All Applications): 0 Submit an original completed and appropriately executed Non -Discharge Permit Ownership/Name Change (FORM: NDPONC 06-16) application. ❑ The Existing Permittee'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 .0106(bl. ❑ 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 .0106(l ). B. Existing Permit (All Applications): 0 Submit a copy of the most recently issued permit. C. Property Ownership Documentation (All Applications): ➢ Per 15A_ NCAC: 02T .0504(1). 15A_ NCAC 02T .0604(e), 15A NCAC 02T .0704(f), 15A NCAC 02T .0804, 15A NCAC 02T .10�d) 15A NCAC 02T .1104(d)(7), 15A NCAC 02T .l 104 e 5 , 15A NCAC 02U .0201(e) or 15A NCAC 02U,.0202(). the Applicant shall demonstrate they are the owner of all property containing the non -discharge system facilities: El Legal documentation of ownership (i.e., GIS, deed or article of incorporation), or ❑ Written notarized intent to purchase agreement signed by both parties with a plat or survey map, or ❑ Written notarized lease agreement that specifically indicates the intended use of the property and has been signed by both parties, as well as a plat or survey map. Lease agreements shall adhere to the requirements of 15A NCAC 02L .0107. D. Certificate of Public Convenience and Necessity (All Applications where the Applicant is a Privately -Owned Public Utility): ❑ Per I SA NCAC 02T .0115(a)(1 ], provide one copy of the Certificate of Public Convenience and Necessity from the North Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the non -discharge system. E. Operational Agreements (All Applications where the Applicant is a Home/Property Owners' Association or Developer of lots to be sold): ➢ Hotne/Property Owners' Associations 0 Per 15A NCAC 02T .0115 c , submit an original properly executed Operational Agreement FORM: 110A . ❑ Per 15A NCAC 02T .01 15c , submit an original proposed or approved Articles of Incorporation, Declarations and By- laws. ➢ Developm of lots to be said ❑ Per 15A NCAC 02T .0115 , submit an original of the properly executed Operational Agreement (FORM: DEV). F. Operation and Maintenance Agreement (All Applications for Single -Family Wastewater Irrigation Systems): ❑ Per 15A NCAC 02T .0604(h], submit an original of a notarized Operation and Maintenance Agreement FORM: SFRW WIS O&M that has been signed and dated by all deeded property owners. THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED TO: NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY DMSION OF WATER RESOURCES WATER QUALITY PERMITTING SECTION NON -DISCHARGE PERMITTING UNIT By U.S. Postal Service: By Courier/Special. Delivery: Non -Discharge Branch Non -Discharge Branch — Archdale 942W By Email: 1617 Mail Service Center 512 N. Salisbury St. Non-Discharge.Reppris _ ncdennoy Raleigh, NC 27699-1617 Raleigh, NC 27604 Telephone Number: (919) 707-3654 INSTRUCTIONS FOR FORM: NDPONC 06-16 & SUPPORTING DOCUMENTATION Page 1 of 1 DocuSign Envelope ID: C64F1 ED7-1419-4E5A-A7A9-A2075E3CE0AB Division of Water Resources I. EXISTING PERMITTEE INFORMATION: State of North Carolina Department of Environmental Quality Division of Water Resources NON -DISCHARGE PERMIT OWNERSHIP/NAME CHANGE FORM: NDPONC 06-16 I. Permittee's name: North Carolina Department of Public Safety 2. Signature authority's name: Jeffrey T O'BrianL PE per 15A NCAC 02T .0106 Title: nirocwr�tj.n�in�rring 3. Permittee's mailing address: 4216 MailService, Center City: Raleigh State: NC Zip: 27699 - 3400 4. Permittee's contact information: Phone number: (1W 716 - 3400 Email Address: jgffny obriantQncdns.gov 5. Demonstration of historical consideration for permit approval — 15A NCAC 02T .0120: Has the Permittee or any parent, subsidiary or other affiliate exhibited the following? a. Has been convicted of environmental crimes under Federal law or G.S. 143-215.6B? ❑ Yes or ❑✓ No b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or ❑✓ No c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes or ✓❑ No d. Is non -compliant with an existing non -discharge permit, settlement agreement or order? ❑ Yes or ❑✓ No e. Has unpaid annual fees in accordance with 15A NCAC 02T .0105(c)(2)7 ❑ Yes or ❑✓ No II. FACILITY INFORMATION: 1 2 Facilityname: Facility's physical address: 13842LNE H= 24_ City: Creswell State: -C Zip: 27928 - III. PERMIT INFORMATION: County: Washington 1. Existing permit number: WQ00 00265 and most recent issuance date: 5/20/2019 2. Existing permit type: Wastewater Irrigation 3. Reason for the permit application: Change of Ownership 4. Has the facility been constructed? ❑✓ Yes or ❑ No IV. APPLICANT INFORMATION: 1. Applicant's name: North Cam1jna EL- rtment of Transsortation 2. Signature authority's name: Stgr i g D Bakm PE,,,Steve Trnwpll per 15A NCAC 02T .0I06(h) Title: Division_ Engineer 3. Applicant's mailing address: 113 AjlpOrt IMMe, ui#e100Environmental Specialist II City: Edenton State: NC Zip: 2 2- 4. Applicant's contact information: Phone number: (2 2 482 - 1850 Email Address: 5. Demonstration of historical consideration for permit approval —15A NCAC 02T .0120: Has the Applicant or any parent, subsidiary or other affiliate exhibited the following? a. Has been convicted of environmental crimes under Federal law or G.S. 143-215.6B? ❑ Yes or ❑✓ No b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or ❑✓ No c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes or ❑✓ No d. Is non -compliant with an existing non -discharge permit, settlement agreement or order? ❑ Yes or ❑✓ No e. Has unpaid annual fees in accordance with 15A NCAC 02T .0105fe)f21? ❑ Yes or ❑✓ No FORM: NDPONC 06-16 Page 1 of 2 DocuSign Envelope ID: C64F1 ED7-1419-4E5A-A7A9-A2075E3CEOAB Existing Permittee's Certification per 15A NCAC 02T .0106(b): 1, Jeffrey T O'Briant, Interim Director of Engineering _ attest that this application for (Signature Authority's name & title from Application Item I.2.) Washington Correctional Center WWTF (Facility name from Application Item H.1.) has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that prior to reissuance of the permit into the Applicant's name, any discharge of wastewater from this non -discharge system to surface waters or the land will 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 the existing permit be violated. I also understand that if all required parts of this application package are not completed and that if all required supporting information and attachments are not included, this application package will be returned as incomplete. I further certify that the existing Permittee or any affiliate 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 do not have any overdue annual fees per 1.5A NCAC 02T .0105(e). 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. Signature: Date: 6/16/2021 1 16:41:36 EDT Applicant's Certification per 15A NCAC 02T ,o1Q6(h): 1, Sterling D Baker, NC Department of Transportation, Division 1 Engineer attest that this application for (Signature Authority's name & title from Application Item IV.2.) Washington Correctional Center WWTF (Facility name from Application Item II.1.) has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that after reissuance of the permit into the Applicant's name, any discharge of wastewater from this non -discharge system to surface waters or the land will 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 package 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. I further certify that the Applicant or any affiliate 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 do not have any overdue annual fees per 15A NCAC 02T .0105(e). 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. f- (b - 6/16/2021 Signature: Date: _ CA 03 7A842 FORM: NDPONC 06-16 Page 2 of 2 a r'^ Al 5 I" Attribute Value NCPIN 7759181395 TAX PIN 7759.00-18-1395 Featld 5969 OwnerAddl 116 W JONES ST OwnerAdd2 c/o STATE PROPERTY OFFICE STATE NC CITY RALEIGH ZIP 27603 DB PG 323/112 DeedDate 1989 SEP 28 OWNER s STATE OF NORTH CAROLINA AreaAC 27.357 PropLoc BEHIND 13842 NC HWY 94 N • rfiL t t �` • i.}��. C R PF., }f 4 . ; , ,• . k 1, + �; , ;. ' +Y r { , .)r 3 �' 41 4 • 1 r!r y Op 4 f' `� � Y•�•N • - y ��p �'-• .. ;ate. "ter I+•y�T _•i.�CkL 1 ! •" 41. + t. •� YR..a ^ .�w'R Attribute Value NCPIN 7759097272 TAX PIN 7759.00-09-7272 Featld 5968 OwnerAddl 116 W JONES ST OwnerAdd2 c/o STATE PROPERTY OFFICE STATE NC CITY RALEIGH ZIP 27603 DB PG 323/112 DeedDate 1989 SEP 28 OWNER s STATE OF NORTH CAROLINA AreaAC 30.661 PropLoc BEHIND 13842 NC HWY 94 N