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Home My WebLink AboutNCG550366_owner (name change)_20230221Environmental Quality National Pollutant Discharge Elimination System (NPDES) Division of Water Resources Application for SURFACE DISCHARGE Certificate of Coverage (COC) Under General Permit NCG550000 For Single -Family Residences and Similar Discharges 100%-domestic wastewater - < 1,000 gallons per day FOR AGENCY USE ONLY Date Received Year Month Day Certificate of Coverage (COC) N C G 5 5 0 Check # Amount Assigned to: The Division of Water Resources will not accept an application package unless all instructions are followed. Failure to submit all required items may result in the application being returned. For more information, visit the Water Quality Permitting Section's NPDES Permitting Unit website. (Press TAB to navigate form) 1. Regional Office Contact: Please contact your DWR Regional Office before submitting this application. If you have not met with your appropriate DWR Regional Office Representative, the application will be returned. Please list the DWR Regional Office representative(s) with whom you have discussed this project: Name(s): Date: Click here to enter a date. 2. Owner's Contact Information: Applicant Type: Owner Name and Title: Street Address: L1 9 ( C Telephone #(H): Cell/Mobile #: 33(0) 3 G 0 Individual ❑ Corporation ❑ Partnership G-01/1 z_ Ue 2)/t Click here to enter text. --7---. be-0 i< 'Vl... State: cfofl O t) L, Zip: Z 7 Cfk Telephone # (W): vaeo Email: , c y cal 5' 1 @ . (t,)/ (f I 3. Location of Facility Producing the Discharge: Please list the address of the facility. If facility is not yet constructed, give street address or lot number. Street Address: `-1 0 0 Z ZO 13 as (IA es5 City: '5t U'N.c i.0 ► \ State: r ! Zip: 2 7 X-( County: eiCL-c_ (tv� - " Telephone #: ` ` Cell/Mobile #: Website: 4. Site -Location Narrative: Please describe how to get to the facility from the nearest town, major highway or identifiable roadway intersection (use street names, state road numbers, and/or distances and directions). Click here to enter text. ndc(-fri 6756L(- J `s of) tip 1-c-R-5L Page 1 of 6 Revised: A. Orlando NPDES 21Sept2017 Application for Certificate of Coverage (COC) and/or Authorization to Construct (ATC) under General -Permit NCG550000 5. Describe the nature of the project. ["New" means has not yet been physically constructed, "existing" means system already physically exists. Please see 15A NCAC 02H .0103(11) for further clarification]. n Installation of a New Wastewater Treatment System (If yes, skip to Number 9.) Expansion of an Existing Wastewater Treatment System (for example, adding bedrooms) (If yes, skip to Number 9.){`" Replacement of an Existing Wastewater Treatment System (If yes, go to Number 6.) 6. Describe the Existing Wastewater Treatment System: n Conventional Septic Tank/Leach-field — Discharge to Sub -Surface Soils. If previously permitted, please attach a copy of the permit or enter the permit number If you are not aware of an existing permit, check here. ❑ Sandfilter — Discharge to Surface Waters [or other, as defined 15A NCAC 02H.0103(11)J. If previously permitted, please attach a copy of the permit or enter the permit number If you are not aware of an existing permit, check here. ❑ ❑ Filter Media System (Pod System)— Discharge to Surface Waters [or other, as defined 15A NCAC 02H .0103(11)]. If previously permitted, please attach a copy of the permit or the permit number. If you are not aware of an existing permit, check here. ❑ Other tjA5,s_re„ Check here if submitting proposal for a new system or if no treatment system exists. 7. Check all EXISTING wastewater treatment components: y4.eptic tank ❑ Dosing tank n UV disinfection ❑ Primary sand filter ❑ Secondary sand filter ❑ Recirculating sand filter(s) ❑ Chlorination ❑ Dechlorination ❑ Other components: ❑ Self -Contained POD system [describe] ❑ Leach Field ❑ Post Aeration (sped type) S. Provide Details of Single -Family Residence (SFR) or Similar Facility: a) Type of facility: Residential ❑ Other: n Commercial b) Amount of wastewater discharged: - Residential: Number of bedrooms 3 x 120 gallons per bedroom = L2D gallons per day (flow) - Commercial: How many employees? (25 gpd/person) Page 2 of 6 Revised: A. Orlando NPDES 21Sept2017 Application for Certificate of Coverage (COC) and/or Authorization to Construct (ATC) under General -Permit NCG550000 c) Is your existing treatment system failing? Yes ❑ d) Has the Health Department formally conde ed your existing system "unsuitable for repair?" Yes ❑ No If yes, please name the Health Department [local, county, or state], and provide the site - inspection date [attach Health Department's judgement letter, if available]: Click here to enter text. Click here to enter a date. If previously permitted [local, county, or state], provide permit number and date issued [attach copy, if available]: Click here to enter text. 9. Check all PROPOSED new system components ❑ Septic tank ❑ Dosing tank ❑ UV disinfection: ❑ Primary sand filter n Secondary sand filter ❑ Recirculating sand filter(s) ❑ Chlorination ❑ Dechlorination n Other components: n Self -Contained POD system [describe] ❑ Post Aeration (specify type) Proposed Modifications to Existing Treatment System - Explain in detail the nature of the modification. Attach all site maps, plans and specifications, signed by an NC Certified Engineer. If prepared by others, plans must conform to 15A NCAC 02H .0139. Click here to enter text. ❑ Proposed New Treatment System for Surface Discharge (not constructed) - Attach all site maps, plans and specifications, to be signed by an NC Certified Engineer. If prepared by others, plans must conform to 15A NCAC 02H .0139. Click here to enter text. Expanding Flow? - Do you propose to increase permitted or existing flow? Yes ❑ No Provide details of the Proposed NEW Discharge [Flow and Source Water]: ❑ Check if same as 6. Existing: Amount of wastewater currently discharged: Number of bedrooms 0 x 120 gallons per bedroom = gallons per day to be permitted (design flow) Expanding: Amount of wastewater proposed to be discharged: Number of bedrooms , x 120 gallons per bedroom = �y�i c� gallons per day to be permitted (design flow 10. Evaluate Alternatives to Discharge to Waters of the State. Please address the feasibility of discharge alternatives as instructed in the NCDEQ Engineering Alternatives Analysis (EAA) Guidance Document found here. (Note: Evaluation for endangered species is not required.) a) Connection to an Existing Wastewater Treatment System - Provide the distance to the nearest connection, such as a regional or municipal sewer system, and the estimated cost per foot to connect including fees. Click here to enter text. Page 3 of 6 Revised: A. Orlando NPDES 21 Sept2017 Application for Certificate of Coverage (COC) and/or Authorization to Construct (ATC) under General -Permit NCG550000 b) Land Application — Assess the land application disposal alternatives such as spray irrigation,' drip irrigation, individual/community onsite subsurface systems, and/or innovative ground -absorption. Questions to consider: (1) Are on -site soils suitable for land application? Yes ❑ No (1 (2) Is there sufficient area on -site? Yes ❑ No ❑ c) Wastewater Reuse — Evaluate reusing all or a portion of the wastewater generated, such as for golf course irrigation, crop irrigation (e.g., hardwood or pine plantation, grasses), athletic field irrigation, landscape uses, and/or commercial/industrial uses. d) On -Site Soil Evaluation — Submit an evaluation of the soils on -site, documented by a certified report from a NC Professional Soil Scientist, or by your local or county health department report (if available).Click here to enter text. e) Cost of Alternatives — Provide an estimation of the cost of each discharge alternative or combination of alternatives. Click here to enter text. 11. Provide Regional Information: Please provide the following information. If you need assistance in obtaining this information, please contact your local DEQ regional office. a) Stream Classification -Verify the stream classification for the nearest downgradient named waterbody. The NC Surface Water Classification map can be found by clicking here. b) Is it a High -Quality Water? If so, check if it is by definition or by designation? In order to check this, ask the Planning Unit. Click here to enter text. c) Map - Provide a map locating the nearest downstream waters -of -the -State (i.e. where the effluent reaches an unnamed tributary, creek, stream, river, or lake via any surface -water conveyance). Click here to enter text. d) Site Evaluation - Contact DEQ's local Regional Office for a site evaluation to confirm the proposed discharge flow path to the nearest waters -of -the -State. The wastewater/stream confluence and stream class must be verified in the field by DEQ's Regional Staff. Please list the Regional Office staff member you contacted for the inspection. Click here to enter text. e) Flow Path - Display graphically the flow path of the discharge to the nearest surface Waters of the State. Document any potential hydrologic trespass or right-of-way infringement on any neighboring property (i.e. note all properties encountered prior to reaching waters -of -the -State). Click here to enter text. f) 7Q10/30Q2 Estimate- Contact USGS J. Curtis Weaver (919-571-4043) to provide the estimated 7Q10 and 30Q2 stream -flow estimates for the first downstream point -of -contact with waters -of - the -State. Page 4 of 6 Revised: A. Orlando NPDES 21 Sept2017 C 0217106(e /0/14 Application for Certificate of Coverage (COC) and/or Authorization to Construct (ATC) under General -Permit NCG550000 11. Certificates of Coverage/Notices of Intent to Discharge/Authorizations to Construct - Check ALL of the following information has been provided. Incomplete Applications will be returned. ❑ An original letter [two (2) copies] requesting coverage under NCG550000. ❑ This application [two (2) copies]. Your signature on this application, certifies that you are legally responsible for the proposed treatment system (see page 6 of 6) for the COC/NOI/ ATC. ❑ A check or money order for $60.00 permit fee made payable to NCDEQ. 12. Additional Application Requirements a) Narrative Description of the treatment system. This narrative should present treatment components in order of flow — influent to outfall, including anti -erosion structures and sample -port location(s). b) Final Plans and Specifications for a wastewater treatment system shall be signed by a North Carolina -registered Professional Engineer, or if prepared by others, must conform to 15A NCAC 02H .0139. All documents are to be stamped "Final Design - Not Released for Construction." Submittal shall include a site map showing the proposed outfall and the effluent proposed path to surface waters -of -the -State. (see Item 1 for location verification by DWR Regional Office staff) c) Submittals by a Consulting Engineer or Engineering Firm shall include: 1. A copy of your written authorization to represent, signed by the legal permit Applicant; and 2. Upon completion of proposed work, a signed copy of DWRs Engineer's Certification form attesting that the project was completed in accord with the DWR approved COC/ATC, as issued. CERTIFICATION I certify that I am familiar with the information contained in this application and that to the best of my knowledge and belief such information is true, complete, and accurate. Printed Name of Person Signing: Title: (Please review 15 date, (Signature of Applicant) (Date Signed) definition of authorized signing officials) /23 Click here to enter a Page 5 of 6 Revised: A. Orlando NPDES 21 Sept2017