WQ0036766_Application_20230717

State of North Carolina
DWR Department of Environmental Quality
Division of Water Resources
Division of Water Resources 15A NCAC 02T .0700 — HIGH -RATE INFILTRATION SYSTEM— RENEWAL
FORM• tM i e 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 he returned. The application and attachments shall be prepared in accordance with 15A
NCAC 02T .0100, 15A NCAC 02T .0700, 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) rile to htts:lledoes.de .nc. ov/Forms/NonDisChar e-Branch-Subm ittal-
Form-Vert, or emailed to Non-Dischar e.Re orts nedenr. ❑v if less than 20 megabytes (MB).
SECTION 11— FACILITY INFOR 4ATION
1, Physical address: Cedar Point Blvd
City: Cedar Point
2. Treatment facility coordinates to the sixth decimal degree:
Latitude: 34.687800
1. Billing address: P:O. 10127
County: Carteret
State: NC
Parcel No.: 537412863976000
,Zip: 28584-
Longitude:-77.75840 Method: Navigation quality GPS
SECTION IV — BILLING INFORMATION
City: Birmingham State: AL Zip: 35202-
2. Verify the Applicant does not have any overdue annual fees:
h s:llde .nc. ovlaboutldivisionslwater-resourceslwater-resources- ennitslw -e a ents
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: FTRIS-R 02-21 Page I of 6

SECTION V — OPERATOR IN RESPONSIBLE CHARGE (ORC) INFORMATION
1. ORC: Lee Buck Grade: III Certification No.: 993396
Mailing address: 1745 Belgrade-Swansboro Road
City: Maysville
Phone number_ [phone] Cell
2. Back -Up ORC: John Blind
Mailing address: 421 oldtowne st
City: jacksonville
Phone number: [phone] Select
State: NC Zip: 28555-
.Em ail: [e-mail]
Grade: 2 Certification No.: 1012677
State: nc .'Lip: 28546-
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 (It) Latitude Longitude
5-Day Upset 537412863976000 77,578 Full, synthetic 34.6880 -77.0760
Select Select _ °
Select Select °
Select Select
SECTION VII—RELATED PERMITS
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
Sewer WQ0036766 Non -discharge permit converted to GW remediation
Select
Select
Select
Select
Select Select
SECTION Vlli — MONITORING WELLS
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
Groulowering
537412863976000
Active
Downgradient
Inside Review Boundary
34.688°
-T7.76°
Groundwater
537412863976000
g
Active
Downgradient
Inside Review Boundary
34.6S80
-77,76'
Groundwater
537412863976000
lowering
Active
Downgradient
inside Review Boundary
34,688°
-77.76°
Select
Select
Select
°
Select
Select
Select
4
Select
Select
Select
a
°
Select
Select
Select
0
Select
Select
Select
p
°
Select
Select
Select
°
V
FORM: HRiS-R
02-21
Page 2 of 6

Select Select Select
Select Select Select
FORM: HRTS-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 .0I05(d). submit a site map pursuant to the requirements in 15A NCAC 02T .0704(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 infiltration areas.
❑ Soil mapping units shown on all infiltration 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 infiltration sites.
El Delineation of the compliance and review boundaries per 15A NCAC 02L ,0107 and in.
❑ Setbacks as required by 15A NCAC 02T .0706.
❑ Site property boundaries within 500 feet of all wastewater treatment; storage, and infiltration sites.
Cl All habitable residences or places of public assembly within 500 feet of all treatment, storage, and infiltration sites.
❑ No — Skip Attachment A.
ATTACHMENT B — SIGNATURE AUTHORITY DELEGATION
Does the signature authority in Section 1, Item 3 meet the requirements pursuant to I SA NCAC 02T .0106 b ?
® Yes — Skip Attachment B.
❑ No — Submit a delegation letter pursuant to 15A NCAC 02T .0106 c authorizing the signature authority to sign.
ATTACHMENT C — FLOW REDUCTION
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 D — CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSffY
Is the Applicant a Privately -Owned Public Utility?
® Yes — Pursuant to 15A NCAC 02T .01 15(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.
ATTACHMENT E — OPERATIONAL AGREEMENT
Is the Applicant a Home/Property Owners' Association or Developer of Lots to be Sold?
❑ Yes (Home/Property Owners' Association) —.Pursuantto l 5A NCAC 02T .0I 15(al(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 O erational AP
areement
fFORI& DEV). Pursuant to 15A NCAC 02T .0115(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 F_
FORM. HRIS-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 .0I 1$ 1 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 III, Item 4 exceed 80%?
❑ Yes (the hydraulic capacity is greater than 801/o) — Pursuant to 15A NCAC 02T .0118(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 ofthe land associated with the wastewater collection, treatment, conveyance, infiltration, and groundwater
lowering (if applicable) system?
® Yes -- Skip Attachment G.
❑ No — Pursuant to 15A NCAC 02T .0I 16c provide a copy of all easements, Iease agreements, and encroachment agreements
allowing the Permittee to operate and maintain the wastewater collection, treatment, conveyance, infiltration, and groundwater
lowering (if applicable) system on property not owned by the Permittee.
_ 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— COMPLIANCE SCHEDULE
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 ,I— CIVIL PENALTIES AND OUTSTANDING VIOLATIONS
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: HRIS-R 02-21 Page 5 of 5

ATTACHMENT K—UNDUSTRLI,L WASTEWATER
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 .0704 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.
ATTACHMENT L — SETBACK WAIVERS
Does the existing permit include setback waivers?
❑ Yes — Pursuant to 15A NCAC 02T .0706 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 15A NCAC 02L .0107.
® No — Skip Attachment L.
1,
APPLICANT'S CERTIFICATION
(Signature authority's name as noted in Section 1, Item 3)
that this application
has been reviewed by me and is accurate and complete to the best of my knowledge. 1. 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 that the applicant, or any
Parent, subsidiary, or other affiliate of the applicant has: not been convicted of enviromental 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 § 143-215.613 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 SU10,11ITTED AS A SINGLE PDF FILE VIA:
Email-
Non-Diseha rize.Reports(&,ncden r.gor
Laserfiche Upload:
htt s:lledocs.de _nc, ovfForms/NunDischar e-Branch-
Su bm itta I -Form -Vert
FORM: KRIS-R 02-21 Page 6 of 6

ATTACHMENT K —:INDUSTRIAL WASTEWATER
Does the wastewater composition in Section I11, 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 Q2T 07Q4 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.
ATTACHMV N1 L—SETBACK WAIVERS --
Does the existing permit include setback waivers? I
❑ Yes — Pursuant to t 5A NCAC 02T . 706 d , provide setbacks waivers that have been wiiaen, notarized, signed by all parties '•
involved, and recorded with the county Register of Deeds. Waivers involving the compliance boundary shall be in accordance
with.] SA NCAC 02L .0107-
® No — Skip Attachment L.
l' attest that this application
(Signature authority's name as noted in Section I, Item 3)
has been reviewed by the and is accurate and complete to the best of my knowledge. l 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 _Q [2t 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 ally 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 02.1. ,0I fl_ 5Ub . An alternate person may he delegated as
the signing official if a letter is provided pursuant to 15A NCAC 02T .0106(c]. Pursuant to § 143-215.6A and § )43-715-68, any
person who knowingly makes any false statement, representation, or certification in any application package shall he guilty of a Class
2misdcmeanor.whiC)XMjjn_de a fine not to exceed $10,000 as well as civil penalties up to $25,00Q per violation.
S igngritre gate: _ : /�z 4
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email. LaserFiche Upload:
Non-Dischyrge, Rem rts(u7nedenr.cov hti s:lledoes.de .nc. ov/Forms/NonDischar e-Branch-
Subm ittal-Form-Vert
FORM: HRIS-R 02-21 Page 6 of