WQ0013874_Application_20230605

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE
WASTEWATER IRRIGATION SYSTEM — CHANGE OF OWNERSHIP
FORM: SFRW WIS-CO 03-21
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 .01001 15A NCAC 02T .0600, 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 htt s://edoes.de .nc. ov/Forms/NonDischar e-Branch-Subniittal-
Form-Vert, or emailed to Non-Dischar e.Re orts nedenr. ov if less than 20 megabytes (MB).
SECTION I—APPLICANT'INFORMATION
1.
Applicant: CRC ED Treatment LLC
2.
Permit No.: WQ0013874
3.
Signature authority: Anna Gaddy
Title: CEO
4.
Mailing address: 7990 NC Hwy 751
City: Durham
State: NC Zip: 27713-6852
5.
Contact person: Susan Frankfort
Primary phone number: [phone] Cell
Email: [e-mail]
Secondary phone number: { ) - Select
b.
Secondary Contact person: Anna Gaddy
Primary phone number: [phone] Cell
Email: [e-mail]
Secondary phone number: ( } - Select
SECTION 1=I — FACILITY INFORMATION
1. Physical address: 7990 NC Hwy 751 County: Chatham
City: Durham State: NC Zip: 27713-6852
SECTION III — BILLING INFORMATION
1. Billing address: 7990 NC Hwy 751
City: Durham State: NC Zip: 27713-6852
SECTION IV — DEED INFORMATION
Has a deed been executed and recorded in the County Register of Deeds pursuant to 15A NCAC 02T .0604(e)(1)?
® Yes — Complete Items 1 through 4 below.
❑ No — See Attachment B on Page 3.
1. Parcel No.: 0020029
2. Date of Purchase: March 25, 2021
3. Deed Book: 2021
4, Deed Page Nos.: 2199 - 0632

SECTION V — OPERATION AND MAINTENANCE AGREEMENT
Permit No.: WQ0013874 County:
a OR"
Permittee: CRC ED Treatment LLC (i.e., all deeded property owners)
The Permittee agrees to operate and maintain the single-family residence wastewater treatment and irrigation system as
follows:
1. Inspect the septic tank annually, and pump out solids as needed.
2. Inspect and clean the septic tank effluent filter annually. (if applicable)
3. Inspect the tablet chlorinator weekly. Add wastewater grade chlorine tablets (e.g., calcium hypochlorite) as needed.
Swimming pool grade chlorine tablets are not acceptable. (if applicable)
4. Inspect the ultraviolet disinfection unit weekly. Clean or replace the lamps and quartz sleeves as needed. (if
applicable)
5. Inspect all storage tanks, pumps, and alarms monthly. Remove the floating scum layer in all pump/storage tanks
when pumping the septic tank solids out.
6. Inspect the spray irrigation system monthly to verify: proper operation of the spray heads; that there are no leaks;
that vegetative growth does not obstruct the spray heads; that the irrigated wastewater is not ponding in or running
off the designated irrigation area; and that there are no objectionable odors. (if applicable)
7. Inspect the drip irrigation system monthly to verify: proper operation of the drip lines; that there are no leaks; that
vegetative growth does not obstruct the drip emitters, that the irrigated wastewater is not ponding in or running off
the designated irrigation area; and that there are no objectionable odors. (if applicable)
8. Maintain a set of Division -approved engineering plans and specifications.
9. Pay the required annual fee.
10. Request renewal of this permit on Division -approved forms no later than 180 days prior to expiration.
11. Sign and provide a Change of Ownership application to any future owner of the single-family residence wastewater
treatment and irrigation system for their completion and submission to the Division of Water Resources.
I/We understand the above requirements and agree to these terms as part of the issued permit.
S
Signature:
Signature:
Signature:
Date: _�Q —
Date:
Date:
Date:
All deeded property owners shall sign this Operation and Maintenance Agreement

ATTACEWENT A —SIGNATURE AUTHORITY DELEGATION
Does the signature authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(bl?
❑ Yes — Skip Attachment A.
® No — Submit a delegation letter pursuant to 15A NCAC 02T .0106(c) authorizing the signature authority to sign.
ATTACHMENT B -- PROPERTY OWNERSMP DOCUAUNTATION I
Has a deed been executed and recorded in the County Register of Deeds pursuant to 15A NCAC 02T .0604(fl(1)?
® Yes — Complete Items 1 through 4 in Section IV on Page 1.
❑ No
❑ Submit a written notarized intent to purchase agreement sign by both parties with a plat or survey map pursuant to 15A NCAC
02T .0604(e)(2); or
❑ Submit a 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 pursuant to 15A NCAC 02T .0604(e)(3). Lease agreements shall adhere to the
requirements of 15A NCAC 02L .0107.
APPI C, ANT'S CERTIFICATION
attest that this application
(Signatire 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 hich may include a fine no I k to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signat Date:
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email:
Non-Discharge.Reportsknedenr.eov
Laserliehe Upload:
htt s:Hedoes.de .ne. ov/Forms/NonDischar e-Branch-
Submittal-Form-Vert
FORM: SFRWWIS-CO 03-21 Page 3 of 3

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ACADIA
11 1: A 1, T 1-1 C A R T
CRC ED TREATMENT, LLC
ACTION BY WIRTTEN CONSENT OF THE MANAGING MEMBER
March 1, 2023
The undersigned, being the managing member of CRC ED Treatment, LLC, a Delaware
limited liability company (the "Company"), does hereby take the following actions by written
consent on behalf of the Company;
WHEREAS, the managing member has determined that it is in the best interests of the
Company to remove the former owner and include CRC ED Treatment, LLC in its place;
WHEREAS, the managing member desires to authorize and approve Anna M. Gaddy,
Chief Executive Officer of the Company, with the authority and power to sign and deliver the State
of North Carolina Department of Environmental Quality Division and Water Resources 15A
NCAC 02T .0600- Single Family Residence Waste Water Irrigation System- Change of Ownership
Form: SFRWWIS-CO 03-21(collectively, the "Documents"), on behalf of the Company; and
NOW, THEREFORE, BE IT RESOLVED, that Ms. Gaddy is hereby authorized as
Chief Executive Officer of the Company, to sign and deliver the Documents on behalf of the
Company; and
FURTHER RESOLVED, that the officers of the Company be, and they hereby are,
directed, authorized and empowered to take such action and do all things that may appear to be, in
the discretion of such officer or officers, necessary, proper or advisable to carry into effect the
purposes and intentions of this and each of the foregoing resolutions; and
FURTHER RESOLVED, that any and all actions heretofore or hereafter taken by the
officers of the Company, or any of thern, be, and they hereby are, approved, authorized, ratified
and confirmed, in all respects, as the act and deed of the Company.
[Signature Page Follows]
4827-6749-5911.2

IN WITNESS WHEREOF, the undersigned has executed these resolutions to be effective
as of the date first written above.
MEMBER:
ACADIA HEALTHCARE COMPANY, INC.
By:
(�—
Christopher L. Howard
Executive Vice President and Secretary
4827-6749-5911.2