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HomeMy WebLinkAboutWQ0013502_Application_20211208State of North Carolina DWR Department of Environmental Quality Division of Water Resources NON -DISCHARGE PERMfiOWNERSHIPINAME CHANGE VNislon of W&tei ReSuurLeS iNSTRUCTIONS FOR FORM: NDPONC 06-16 & St1PPORT1NG DOCUMENTATION This forest is for ownership Changes or name Changes of a non -discharge system perm1L Please note that "Permittee" references the existing permit holder, aad that "Applicant" references the entity applying for the ow aershipinainc change. For more information, visit the Water Qualirs, Permitting Section ;s No" -Discharge PermhWAg limit _ A. Non -Discharge Permit Ownership/Name Change (FORM: NDPONC 06-16) Application (All Applications), - El Submit an original Completed and appropriately executed Non -Discharge Permit Ownership/Name Change (FORM: NDPONC 06-16) application. ❑ The Existing Permittrc's Certification shall be signed in accordance with _. Per i1 I ia,L an alternate person may be designated as the signing official ifa delegation letter is provided from a perm who meets the criteria in El The Applicant's Certification shall be signed in accordarnye with Per an altetnatn person may be designated as the signing official if a delegation letter is provided from a person who meets the criteria in 1 B. Existing Permit (All Appficatiorts): El Submit a Copy of the most recently issued permit. C. Property Ownership Documentation (All Applications): ➢ Per :1 :[ :It {1=' { .0�(A4IL 15A N1L'A( et' 1 .wit) -lie!_ 1t .It tl-' 1 j1•'{llt t•I, i it2 i 1181141 I i 1 1e 14 II_'_ I if. .• - ` ...•, if 021 11il•tr. .. - = L �[ •Le' r1' i i :+i+`1, .' = 1 'tie L1 ie'i r1`el'r,•j or ?'+.I the ApplicW11 shall demonstrate they are the owner Wall property containing the non -discharge system facilities: El Legal documentation of ownership (i.e., , deed or article of incorporation). or ❑ Written notarixnxl 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 D. Certificate of Public Convenience and Necessity (All Applications where the Applicant is a Privately -Owned Public Utility): ❑ Per 1; L \4';It {I' I .r11 ! i , provide one copy of the Ccrtificaw of Public Convenience and Necessity From the ' • nrr,liri. [ i title•, e actual 1' •i: demonstrating the Applicant is authorized to hold the u6tity franchise for the area to he served by the non -discharge system. F. ❑perationaI Agreements (All Applications where the Applicant is a Home/Property Owners Association or Developer of lots to tk soldJ: Ilomefpromrty Owners' &r dSiations ❑ N.-r t1 : l ..::. , ,submit an original properly executed [ ltx r.at oval 1 r rr:rnl f_Fs l!t'►4: 1 !i 1:. El Per 1,iA \C _U 1 131c :, submit an original proposed or approved Articles of Incorporation, Declarations and By- laws. ➢ Developers of lots to be sold ❑ Per - _ __ -- -submit an original ofthe properly executed �[k o:rl r, n,el iir4 i 1nt r1l I I { af: �i: 111 1' !• F. Operation and Maintenance Agreement (Ali Applications for Singlc�-Family Wastewater Irrigation Systems): ❑ Per submit an original of a notarized a rtu•r;or.rn .Inri ■f, nt1 +:un r .1 :.r4•L•111L-:i1 I t fliol tit R 1L IS o that has been signed and dated by all deeded property ownem THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITCII;D TO: NORTH CAROLINA DEPA I'MENTOF ENVIRONMENTAL QUALITY 1 1"SION OF WATER RESOURCES WATER QUALITY PERMITTING SECTION NUN -DISCHARGE PERMMITTiNG UNIT Ili• US. Postal Service: By Courieri5pecial Delivery: By Email Non -Discharge Branch Non -Discharge Branch —Archdale 942W 1617 Mail Service Center 512 N. Salisbury St Raleigh, NC 27699-1617 Raleigh, NC 27604 Telephone Number: (919) 707-3654 INSTRUCTIONS FOR FORM: NDPONC 06-16 & SUPPORTING DOCUMENTATION Page I of I State of North Carolina DWR Department of Environmental Quality Division of Water Resources NON-DISCII ARG E PERMIT OVVNERS141P/NAME CHANGE Uhl -,Jon of Water lllrsoueces FORM: NDPONC 06-16 1. EXISTING PERMITTEE INFORMATTION: 1- Permittee's name: Dale D. Faulkner 2. Signature: authority's name: Randall Jarrell per I �A NL :1[' 0' I _[I I06 b i Title: OK 3. Permittec's mailing addresS: 482 Kutbush Farm Hoad :l 5 City: Henderson State: NC Zip: 27537 Permi#Ws contact information: Phone number: (_T ) 548 - z5G6 Email Address: ddfaulkner@bellsouth.net Dcmonslration of historical consideration for permit approval — 15A NC'A(_ 4)2 l .5r120- Has the Perm ittee or any parent. subsidiary or other affiIiate exhibited the following? a. Has been convicted of environmental crimes under Federal law or (,.S. 14�? 1 �A tp ❑ Yes or ✓❑ No b. Has previously abandoned a wastewater treatment Facility without properly closing that facility? ❑ Ycs or Q No c. Flas unpaid civil penalty where all appeals have Num abandoned or exhausted? ❑ Yes or 0 No d. Is non -compliant with an existing non -discharge permit, settlement agreement or order! ❑ Yes or 0 No e. Has unpaid annual fees in accordance with I ` 1 M V t i ' I o, I ti ,i , i't ❑ Yes or ✓❑ No IL FACILITY INFORMATION: 1_ Facility name: Towers Apartments WWTF 2. Facility's physical address: 3995 Jones Ferry, LLC City.: Chapel Hill %Iatc: NC Zip: n516 _ County: chatbam ■ RI. PERMIT INFORMATION: 1. Existing permit number: WQOO 13502 and most recent issuance date: 8I3 /2019 2. Existing permit type: wastewater {rrlption • 3. Reason for the permit application: Change otowneroip • 4. 1 las the facility been constructed? ✓❑Yes or ❑ N❑ IV. APPLICANT INFORMATION: I. Applicant's name: 3995 Jones Ferry, LLC - Chad Leinbach 2. Signattue authority's name: Kenneth Chad Leinbach Xi -1 i 01,1 , I1lie• OwnerjORC 1 Applicant's mailing address: 1284 windy Ridge Road City: Chapel Hill state: roc- Lip. 27517 _ W6 4. Applicant's contact information: Phone number: i 2 1 z - 7301 Email Address- chad•leinhach@gmail_com 5. Demonstration ofhistorical consideration for permit approval --- ____' : .ii i '•.1; Has the Applicant or any parent, subsidiary or other affiliate exhibited the followirg, a. I tas been convicted of environmental crimes under Federal law or ! _ � I I I :7 ❑ Ycs or ❑ No b_ Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or El No c. I1as 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 r❑ No c. Has unpaid annual fees in accordance with I iA Ne ( ' tf ' I u I (1s1S;1[_1 ❑ Yeas or ✓❑ Nn FORM: NDPONC 06-16 Page 1 oF2 Existing Permirtee's C'ertifiestion per I, Bale D. FauL ncr — — — attest that this applica ioa for tsiguature Autltorttp's name & tttle f urn Applicatiam Itcm i.2.j Towcrs Apartments ► VJTF — — - (Rwility rtamc froin Applicaticsn Item R.I.I hag bL.cn reviewed by nw =id is accurate and caIIrpkU to the best of my Ecnow•kdge. I understand that prior to rcissuancc of the perinit into thti Applicant's neuter, any di wharp .. of w.—w w wcr frimr this non•dischxrge system to surface waters or the land will result in an enforcement action that trsty inchxic civil peiudtiv%, snluncil m rchcf, and-ur t rrmmal prusecution- I will rtokc no claim against the Division of Watcr Rcsawtt-s should a condititrn of the existing p4-rmit be. violatal. I also understand that tt-all requm-d pans of this application package we not completed and that if all required Supporting infcrrt:uttivn and attachments m not included. thus applicanon package will be rcuirmd as incompicte. I fudher txdify that the: existing Pcrmiucc or any ali'tltatc has not bcon convicted of an environmental cri. w. IL&s riot aMndoned a wame-wac'r facility widumt proper clear, dues not have an out%tandme crVil penalry wttcrr alt appeals have been exhaw%led tit abaadartctL we Lompliant with any zwtivc ixrasplianm sch-LduJc, and do not have any (nerduc anttuarl tccs per 1 fry NC A Ctl. F.01 t1Sty s. NOTE It: accorekuUc with General titntutcs - I '� and any lxiwn who kiu-)wingly nu- k- s any bLsc statcrnenl� r�ItrL�c nt:rlion, Of Curtificauion in troy applic itoon pae kagc shall be guilty of a Class ? mts&mcanor, which may incfudc a. fine not to exe coe3 $ tO,Odl[t as ►Melt as creel �M7a;l, vnaio St&maturc: 11412021 -,-. Applicant's C.ertifwatinn per 15,%N( AC Ei:I 010kl 1- 1 KL-tsnr.th Chad i.rsnh:u h, t vAw& Tow-c7$ Apamwats iY)W TIl: (Sivult v Authemr_y's natne & title from Applwitm Item iV.2_} (Facility name from AIVIitatinn Item 11.1.1 attest that this appl ication for lxs been rcNiewed by me and is accurate and comlilde to the beast of any kncrwlct[Igc I understand that after remstumcr of the permit into the Applicant's tame, any discrarirc (if wWcwstv7r fmin this grim-&:dra ry %)—sivat to surf icc waters or epee land will msult in an cnturcement at:uon that may include civil "alum, injunctive: selie:f, antl.•'or criminal pni,%Lxution I will make no claim against the Division of Watcr Rescurccs should a cmAition of the; permit be violated I al,o trhxie^r,"- that if a rtaquitzd part,% of this application package arc not completed and that if all required supportins, information and aiachtncrits are nor inclutW, this awlicahism package: will etc returned to me as tntompliic. 1 further ccMty that the Applicant ar any affiliate has not been cexiviCCC41 Of an 4nv ir+xnne7nrxl crime, has not abandoned a waatew•ater factluy without groper closure_ ikxs net have an out-i"inv, civil pcitalty *11wie all aplwal'. Itavc been cxhaust"J or abandoned, arc compliant with any active compliance schedule, and do sari hart any overdue annual feces lwz \is .'I I ' 1;1. DOTE - In stew >danee with General cvWuEeA . l ', r, and - -It, any perstin who k-mmingly makes ,any false statcment. representation, or cenificabon in any applicatiurt package 4WI be guilty of x ('Less 2 miuletneanor, whx:Ii may tnciude. a fine not to exceed 5 i0.000 ass cll ai civil CSS25.000 per vierlation. I1,42021 FOP,M: NDPONC W16 Pare 2 of 2 S. cz U S. 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