WQ0013808_Renewal Application_20230124

Initial Review
Reviewer Thornburg, Nathaniel D
Is this submittal an application? (Excluding additional information.)*
Yes No
Permit Number (IR) * WQ0013808
Applicant/Permittee Kotis Properties, Inc.
Applicant/Permittee Address P.O. Box 9296; Greensboro, NC 27429
Is the owner in BIMS? Yes No Is the facility in BIMS?
Owner Type
Facility Name
County
Fee Category
Is this a complete application?*
Yes No
Signature Authority
Signature Authority Title
Signature Authority Email
Document Type (if non -application)
Email Notifications
Organization
Summerfield Shopping Center WWTF
Guilford
Does this need review by the hydrogeologist? * Yes No
Regional Office
CO Reviewer
Admin Reviewer
llr�ore
Fee Amount $0
Complete App Date 01/24/2023
Below list any additional email address that need notification about a new project.
... ... ..
Email Address
Comments to be added to email notfication
Comments for Admin
Comments for RO

Comments for Reviewer
Comments for Applicant

Submittal Form
Project Contact Information
Please provide information on the person to be contacted by NDB Staff regarding electronic submittal, confirmation of receipt, and other correspondence.
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Name* Brian Gaster
Email Address*
[e-mail]
Project Information
Application/Document Type*
New (Fee Required)
Modification - Major (Fee Required)
Renewal with Major Modification (Fee
Required)
Annual Report
Additional Information
Other
Phone Number*
[phone]
Modification - Minor
Renewal
GW-59, NDMR, NDMLR, NDAR-1,
N DAR-2
Residual Annual Report
Change of Ownership
We no longer accept these monitoring reports through this portal. Please click on the link below and it will take you to the correct form.
hftps://edocs.deq.nc.gov/Forms/NonDischarge_Monitoring_Report
Permit Type: * Wastewater Irrigation
Other Wastewater
Closed -Loop Recycle
Single -Family Residence Wastewater
Irrigation
Permit Number: * WQ0013808
Has Current Existing permit number
Applicant/Permittee* Kotis Properties, Inc.
Applicant/Permittee Address* P.O. Box 9296; Greensboro, NC 27429
Facility Name* Summerfield Shopping Center WWTF
Please provide comments/notes on your current submittal below.
High -Rate Infiltration
Reclaimed Water
Residuals
Other
At this time, paper copies are no longer required. If you have any questions about what is required, please contact Nathaniel Thornburg
at [e-mail].
Please attach all information required or requested for this submittal to be reviewed here.
(Application Form, Engineering Plans, Specifications, Calculations, Etc.)
2023 Wastewater Irrigation Permit Renewal.pdf 855.44KB
Upload only 1 PDF document (less than 250 MB). Multiple documents must be combined into one PDF file unless file is larger
than upload limit.
* By checking this box, I acknowledge that I understand the application will not be
accepted for pre -review until the fee (if required) has been received by the Non -
Discharge Branch. Application fees must be submitted by check or money order and
made payable to the North Carolina Department of Environmental Quality (NCDEQ).
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).
Mail payment to:
NCDEQ — Division of Water Resources
Attn: Non -Discharge Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Signature

Submission Date 1/24/2023

DWR
Division, of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0500 — WASTEWATER IRRIGATION SYSTEM — RENEWAL
FORM: WWIS-R 02-21
Pursuant to 15A NCAC 02T .0107(b), if the application does not include all required information and the necessary
supporting documentation, the application shall be returned. The application and attachments shall be prepared in
accordance with 15A NCAC 02T .0100, 15A NCAC 02T .0500, and Division Policies. For more information, visit the Water
Quality Permitting Section's Non -Discharge Branch website. The Applicant shall submit an electronic copy of the application
and attachments uploaded as a single Portable Document Format (PDF) file to https:11edoes.deg.nc.gov/Formst.NonDischar«,Le-
Branch-Submittal-Farm-Ver2, or emailed to Non-Discharge.Reportsrnedenr.aov if less than 20 megabytes (M13).
SECTION I — APPLICANT INFORMATION
1.
Applicant: Kotis Properties, Inc.
2.
Permit No.: WQ0013808
3.
Signature authority: William Kotis, Jr.
Title: President
Phone number: [phone] Office
Email: [e-mail] (Mr. Kotis does not have
email)
4.
Mailing address: P.O. Box 9296
City: Greensboro
State: NC Zip: 27429-9296
5.
Contact person: Brian C. Gaster
Email: [e-mail]
Primary phone number: [phone] Cell
Secondary phone number: [phone] Office
ION II FACILITY
1. Physical address: 4548 US Highway 220 North
City: Summerfield
2. Treatment facility coordinates to the sixth decimal degree:
FORMATION'
County: Guilford
State: NC
Parcel No.: 146037
Zip: 27358-9412
Latitude: 36.19082' Longitude:-79.88987' Method: Navigation quality GPS
1.
SECTION II I — F L 6VINF10RMATI0N
Permitted flow: 3600 GPD (The maximum allowable flow based on what has been permitted)
2.
As -built flow: 3100 GPD (The maximum allowable flow based on what has been constructed)
3.
Average flow: 1500 GPD (The average of all reported flows on the previous calendar year's NDMRs)
4.
Hydraulic capacity: 48 % (Divide the average flow in Item 3 by the As -built flow in Item 2)
5.
Wastewater composition: Domestic: 100 % Industrial: % Stormwater: %
SECTION IV —BILLING INFORMATION
1. Billing address: P.O. Box 9296
City: Greensboro State: NC Zip: 27429-9296
2. Verify the Applicant does not have any overdue annual fees:
littps://deq.ne. gov/about/divisions.•'water-resoui-ceshvater-resources-perm its/wq-epgyments
Pursuant to 15A NCAC 02T .0120(c), permits for renewing facilities shall not be granted if the Applicant or any affiliation has
an unpaid annual fee.
FORM: WWIS-R 02-21 Page 1 of 6

SECTION V — OPERATOR IN RESPONSIBLE CHARGE (ORQ INFORMATION
1. ORC: Chad Leinbach Grade: SI/WW2 Certification No.: 23928
Mailing address: 1284 Windy Ridge Road
City: Chapel Hill State: NC Zip: 27517-6486
Phone number: [phone] Cell Email: [e-mail]
2. Back -Up ORC: Bradley Flynt Grade: WWIV Certification No.: 27171
Mailing address: 8467 Southard Road
City: Stokesdale State: NC Zip: 27357-8202
Phone number: (336) 587-330 Office Email: [e-mail]
SECTION VI -- OPEN -ATMOSPHERE STRUCTURES
1. List all open -atmosphere treatment and storage structures associated with the renewing permit. Attach additional sheets if
necessary.
Type Parcel No. Volume (gal) Liner Type Freeboard (ti) Latitude Longitude
Storage 146037 550,000 Full, synthetic 2 36.190460-79.890000
Select
Select
0_
0
Select
Select
0_
0
Select
Select
0_
0
T
1. List all wastewater permits (i.e., sewer, collection system, NPDES, residuals) that have interactions with the renewing permit.
Attach additional sheets if necessary.
Permit Type
Permit No.
Relationship Type
Select
Select
Select
Select
Select
Select
Select
Select
I; DNIT[lR1NG WEL.
1. List all groundwater monitoring wells associated with the renewing permit. Attach additional sheets if necessary.
Well Name
Parcel No.
Status
Gradient
Location
Latitude
Longitude
Select
Select
Select
°
- °
Select
Select
Select
°
- °
Select
Select
Select
°
- °
Select
Select
Select
°
- °
Select
Select
Select
°
-
Select
Select
Select
°
-
Select
Select
Select
°
-
Select
Select
Select
°
-
Select
Select
Select
°
-
Select
Select
Select
°
- 0
Select
Select
Select
°
-
FORM: WWIS-R 02-21 Page 2 of 6

SECTION 1�&IR.RIGATION FIELDS
1. List all irrigation fields associated with the renewing permit. Attach additional sheets if necessary.
Field
County
Parcel No.
Deeded Owner
Area
Cover Crop
Latitude
Longitude
1
Guilford
146037
Kotis Properties, Inc.
0.71
Madison
36.1911630
-79.8902910
2
Guilford
146037
Kotis Properties, Inc.
0.52
Madison
36.1916860
-79.8892080
3
Guilford
146037
Kotis Properties, Inc.
0.17
Madison
36.1912990
-79.8891790
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total Acreage:
1.40
FORM: WWIS-R 02-21 Page 3 of 6

ATTACHMENT A — SITE MAP _._...._
Was the facility originally permitted or had a major modification issued after September 1, 2006?
❑ Yes — Pursuant to 15A NCAC 02T .0105(d), submit a site map pursuant to the requirements in 15A NCAC 02T .0504(d).
These requirements are:
❑ A scaled map of the site with topographic contour intervals not exceeding 10 feet or 25 percent of total site relief and
showing all facility -related structures and fences within the wastewater treatment, storage, and irrigation areas.
❑ Soil mapping units shown on all irrigation sites.
❑ The location of all wells (including usage and construction details if available), streams (ephemeral, intermittent, and
perennial), springs, lakes, ponds, and other surface drainage features within 500 feet of all wastewater treatment, storage,
and irrigation sites.
❑ Delineation of the compliance and review boundaries per I5A NCAC 02L .0107 and .0108, and 15A NCAC 02T .0506(c)
if applicable.
❑ Setbacks as required by 15A NCAC 02T .0506.
❑ Site property boundaries within 500 feet of all wastewater treatment, storage, and irrigation sites.
❑ All habitable residences or places of public assembly within 500 feet of all treatment, storage, and irrigation sites.
® No — Skip Attachment A.
.ATTACHMENT B SIGNATURE AUTHORITY DELEGATION
Does the signature authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)?
® Yes — Skip Attachment B.
❑ No — Submit a delegation letter pursuant to 15A NCAC 02'T .0106(c) authorizing the signature authority to sign.
ACHMEN T'' C - FLOW R CTION
Does the existing permit include an approved flow reduction?
❑ Yes — Submit a copy of the flow reduction approval letter, as well as 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 flow reduction value, the Permittee shall provide a reevaluation of the reduced flow value pursuant to the
requirements in 15A NCAC 02T .0114(fl.
® No — Skip Attachment C.
ATTACHMENT 1i— CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY
Is the Applicant a Privately -Owned Public Utility?
❑ Yes — Pursuant to 15A NCAC 02T .0115(a)(1), submit the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise.
® No — Skip Attachment D.
_r ATTACHMENT E— OPERATIONAL AGREEMENT
Is the Applicant a Home/Property Owners' Association or Developer of Lots to be Sold?
❑ Yes (Home/Property Owners' Association) — Pursuant to 15A NCAC 02T .0115(a)(2), submit an executed Operational
Agreement (FORM: HOA). Pursuant to 15A NCAC 02T .0I 15(c), if the applicant is a legally formed Homeowners' or Property
Owner's Association, submit a copy of the Articles of Incorporation, Declarations, and By-laws.
❑ Yes (Developer of Lots to be Sold) — Pursuant to 15A NCAC 02T .0115(a)(2), submit an executed Operational Agreement
(FORM: DEV). Pursuant to 15A NCAC 02T .01 15(b) if the applicant is a developer of lots to be sold, submit a copy of the
Articles of Incorporation, Declarations, and By-laws.
® No — Skip Attachment E.
FORM: WWIS-R 02-21 Page 4 of 6

ATTACHMENT F — DEMONSTRATION OF FUTURE WASTEWATER TREATMENT CAPACITIES
Is the applicant a municipality, county, sanitary district, or public utility?
❑ Yes — Proceed to the next question.
® No — Skip Attachment F.
Does the hydraulic capacity in Section III, Item 4 exceed 70%?
❑ Yes (the hydraulic capacity is greater than 70%, but less than 80%) — Pursuant to 15A NCAC 02T .01180) prior to exceeding
80 percent of the system's permitted hydraulic capacity (based on the average flow during the last calendar year), the permittee
shall submit an engineering evaluation of their future wastewater treatment, utilization, and disposal needs. This evaluation
shall outline plans for meeting future wastewater treatment, utilization, or disposal needs by either expansion of the existing
system, elimination or reduction of extraneous flows, or water conservation and shall include the source of funding for the
improvements. If expansion is not proposed or is proposed for a later date, a justification shall be made that wastewater
treatment needs will be met based on past growth records and future growth projections, and as appropriate, shall include
conservation plans or other measures to achieve waste flow reductions.
❑ Yes (the hydraulic capacity greater than 80%) — Proceed to the next question.
® No — Skip Attachment F.
If answered Yes above, does the hydraulic capacity in Section II1, Item 4 exceed 80%?
❑ Yes (the hydraulic capacity is greater than 80%) — Pursuant to 15A NCAC 02T .01 18(2), prior to exceeding 90 percent of the
system's permitted hydraulic capacity (based on the average flow during the last calendar year), the permittee shall obtain all
permits needed for the expansion of the wastewater treatment, utilization, or disposal system and, if construction is needed,
submit final plans and specifications for expansion, including a construction schedule. If expansion is not proposed or is
proposed for a later date, a justification shall be made that wastewater treatment needs will be met based on past growth records
and future growth projections, and as appropriate, shall include conservation plans or other specific measures to achieve waste
flow reductions.
® No — Skip Attachment F.
ATTACHMENT G —EASEMENT, ENCROACHMENT, AND LEASE AGREEMENTS
Does the Permittee own all of the land associated with the wastewater collection, treatment, conveyance, and irrigation system?
® Yes — Skip Attachment G.
❑ No — Pursuant to 15A NCAC 02T .0116(c), provide a copy of all easements, lease agreements, and encroachment agreements
allowing the Permittee to operate and maintain the wastewater collection, treatment, conveyance, and irrigation system on
property not owned by the Pennittee.
ATTACHMENT H —AFFILIATIONS
Are the Permittee's affiliations of record correct? Check affiliations.
® Yes — Skip Attachment H.
❑ No — Provide the corrected affiliations and their contact information.
ATTACHMENT I—COMPLLk-NCE SCHEDULES
Does the existing permit include any Compliance Schedules? (See Section I of the most recently issued permit)
❑ Yes — Submit documentation that the compliance schedules have been met.
® No — Skip Attachment I.
ATTACHMENT J -- CIVIL PENALTIES AND OUTSTANDING VFOLAiTIONS
Does the Permittee have any existing civil penalties or outstanding violations?
❑ Yes (civil penalties) — Submit payment for the civil penalty, or proof of remission request.
❑ Yes (violations) — Submit a copy of your response to the Notice of Violation.
® No — Skip Attachment J.
FORM: WWIS-R 02-21 Page 5 of 6

A:TTACHAI ENT K — INDUSTRIAL WASTEW ATER
Does the wastewater composition in Section III, Item 5 include any industrial wastewater?
❑ Yes — Proceed to the next question.
® No — Skip Attachment K.
Has the nature of the industrial wastewater changed since the last permit issuance (i.e., changes in industrial process, introduction
of new materials or chemicals, etc.)?
❑ Yes — Provide a chemical analysis of the wastewater pursuant to the requirements in 15A NCAC 02T .0504(h). Provide an
overview of the manufacturing process; an inventory of all chemical and biological materials used in the manufacturing
process; and an overview of the cleaning and treatment methodology.
® No — Provide an overview of the manufacturing process; an inventory of all chemical and biological materials used in the
manufacturing process; and an overview of the cleaning and treatment methodology. WC 1 o+ h Q , s L `l S'w
,aA.1.► . wry �..'..� �.. �:s
ATTACHMENT L — SETBACK WAIVERS
Does the existing permit include setback waivers?
❑ Yes — Pursuant to 15A NCAC 02T .0506(d), provide setbacks waivers that have been written, notarized, signed by all parties
involved, and recorded with the county Register of Deeds. Waivers involving the compliance boundary shall be in accordance
with 1.5A NCAC 02L .0107.
® No — Skip Attachment L.
APPLICANT'S CERTIFICATION
I, w i 1 V Kn►► V—a + "b J c , attest that this
(Signature authority's name as noted in Section I, Item 3)
has been reviewed by me and is accurate and complete to the best of my knowledge. I 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 pursuant to 15A NCAC 02T .0120(b), that the applicant, or
any parent, subsidiary, or other affiliate of the applicant has: not been convicted of environmental crimes under; not previously
abandoned a wastewater treatment facility without properly closing the facility; not paid a civil penalty; not been compliant with
any compliance schedule in a permit, settlement agreement, or order; not paid an annual fee.
Note: The Applicant's Certification shall be signed pursuant to 15A NCAC 02T .0106(b). An alternate person may be delegated
as the signing official if a letter is provided pursuant to 15A NCAC 02T .0106(c). Pursuant to § 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:
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email:
Non-D isch a rge. Re po rts(a)ncden r. gov
Laserfeche Upload:
https: //edoes.deo. ne. zov/Forms/Non ©ischa r2e-Bran ch-
Suhmittal-Form-Vert
FORM: WWIS-R 02-21 Page 6 of 6

FaAS gs
"`• NORTH C ROLINA
a Environmental Quality
Water Quality Online Payments Receipts
Annual Permit Fees
WARNING: Do not click on your browser's back button! Doing so may cause another
payment to be processed!
Thank you for your payment.
Payment Type:
Amount Paid:
_VISA
$831.47
Date Paid:
1/13/2023 _
Confirmation number:
23011357513573
Authorization Code:
113195
Disclaimer: The ePayments System will not be updated immediately with your payment
transaction until the next business day. Therefore, paid invoices
will continue showing outstanding in the system until 1 business day or 24 hours after
the transaction was made.
Would you like to pay another invoice?
Pay for another facility
Should you have any questions regarding an invoice, billing, or the ePayment System,
please contact the Annual Administering and Compliance Fee Coordinator
at 919-807-6316 or Wq![e-mail] (mailto:wgep�y n d nr ov .