WQ0002284_Renewal (Application)_20070928

State of North Carolina
Department of Environment and Natural
Division of WaterQuality'
SEP 2 8 2007
INSTRUCTIONS FOR FORM: 06
(RENEWAL WITHOUT MODIFICATION OF WASTEWATER NO -DI. ARGE..Sys-TEE$ -
WASHINGTON REGIOHAL OFF CE
For more information or for an electronic version of this form, visit the Land Ap lication Unit (LAT9 web site at
http: //h2o. enr.state. nc. uOaulmain. html
This form is for renewal without modification for all wastewater non -discharge systems. Wastewater non -discharge
systems include: High Rate Infiltration Systems; Infiltration/Evaporation Lagoons; Reclaimed Water Utilization
Systems; Wastewater Recycle Systems; Single Family Surface Irrigation Systems; and Surface Irrigation Systems.
This application may not be used for renewal of Land Application ofResiduals Permits.
A. Application Form (All Application Packages):
✓ Submit one (1) original and two (2) copies of the completed and appropriately executed application form.
Any changes made to this form will result in the application package being returned.
✓ If the Applicant is a corporation or company, it must be registered for business with the NC Secretary of
State (hilp://www.secretary.state.nc.us/CoMprations/CSearch.aspx).
✓ If the Applicant is a partnership, sole proprietorship, trade name, or d/b/a enclose a copy of the certificate
filed with the register of deeds in the county of business.
✓ The application must be signed appropriately in accordance with 15A NCAC 2T .0106(b). An alternate
person may be designated as the signing official, provided that a delegation letter is provided from a person
who meets the referenced criteria. You may download an example delegation letter from the LAU web site.
✓ Submit three (3) copies of the most recently issued existing permit.
B. Additional Forms (Single Family Residence Surface Irrigation Systems Only):
✓ Submit one (1) original and two (2) copies of a completed and properly executed FORM: SFR O&M. This
Form may be downloaded at: htip://h2o.enr.state.nc.us/lau/applications.html#Single
C. Site Map
✓ Submit three (3) copies of an updated site map if required as part of the original submittal in accordance
with 15A NCAC 2T .0105(d).
I. GENERAL INFORMATION: I ,, �/ % l
1. Permittee's name (Owner of the facility): C)L)+e,l &4L S �I�IyCtirzt= � A 5S OC L
2. Complete mailing address of Permittee: P, 0 , -ktl* ? 8�0
City. & 0 y State: &2 C Zip: 2-:7 4) G
Telephone number: (Z.r 2) - q S' - 3 3 0 Z Facsimile number: 2 2) 2 9S - 3 8 3 i
Email Address: 1i
3. Facility name (name of the subdivision, shopping center, etc.): UU 49 f O'asL K.S/ K-1do r.�
WW TP uA k=f_- Ajbre5
4. Complete address of the physical location of the facility (if different from above):
City:
5. County where project is located:
State:
Zip:
6. Name and affiliation of contact person who can answer questions about project: 1UA V S' l
k„( t UI q i n eG r Email Address: Mg ®,Cp,a%
FORM: WWR 09-06 Page 1

H. PERMIT INFORMATION:
1. Existing permit numberand the issuance date 3 / JaiYLLtQr2,06-1
2. Existing permit type:
❑ High -Rate Infiltration ❑ Evaporation Lagoons
❑ Single Family Surface Irrigation ❑ Surface Irrigation
5?0R'eclaimed Water Utilization
❑ Wastewater Recycle
3. Has the treatment and disposal system been constructed? 2*''Yes ❑ No
4. If the system has not been constructed, would you like to rescind your permit (i.e. the permitted facilities
will not be needed)? ❑ Yes ❑ No iv/fh
5. Has the wastewater system been connected to a municipal or community sewer system? ❑ Yes [j�oNo
Applicant's Certi$catlon [signing authority must be in compliance with 15A NCAC 2T .0106(b)]:
I,
authority name and title)
attest that this application for
(facility name)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that any discharge
of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against
the Division of Water Quality should a condition of this permit be violated. I also 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 to me as -incomplete. I further certify that the applicant or
any affiliate has not been convicted of an environmental crime, has not abandoned a wastewater facility without
proper closure, does not have an outstanding civil penalty where all appeals have been exhausted or abandoned, are
compliant with any active compliance schedule, and do not have any overdue annual fees under Rule 2T .0105.
Note: In acc with NC GenoalStatutes 143-215.6A and 143-215.613, any person who knowingly makes any
false statement, entation, or 46rdfication in any app tion package shall be guilty of a Class 2 misdemeanor,
which may incl a fine not to 10,Q00 as civil penalties up to $25,000 per violation. _
=_1 2`Z -�
THE COMPLETED RENEWAL APPLICA'FI X911ALL BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
By U.S. Postal Service:
1636 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1636
TELEPHONE NUMBER: [phone]
By Courier/Special Delivery:
2728 CAPITAL BOULEVARD
RALEIGH, NORTH CAROLINA 27604
FAX NUMBER: [phone]
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