WQ0031857_Renewal (Application)_20240124

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02U - RECLAIMED WATER SYSTEM - RENEWAL
FORM. RWS-R 42-21
Pursuant to 15A NCAC 02T .0107(b), if the application does not include all required information and the necessory
supporting documentation, the application shall be returned. The application and attachments shall be prepared in
accordance with 15A NCAC 02T .0100, 15A NCAC 02U, and Division Policies.. For more information, visit the Water Quality
Permitting Section's Nan-Diwbarge $ranch website. The Applicant shall submit as electronic copy of the application and
attachments uploaded as a single Portable Mrument Format (PDF) file to https:lledoes.deg.nr.2ovYForms/NolaDischttr>re;
Branch-Sabmiittol-Form-Ver2, or emailed to Non- Discharze.Reporfsl }u.ncdenr.Eov if less than 20 megabytes (MB).
SECTION I - APPLICANT INFORMATION
I . Applicant: Town of Oak Island
2. Permit No,: WQ0031857
3. Signature authority: David Kelly It
Phone number: (910) 2 7 8 - 5 D I l Select
Title: Town Manager
Email. [e-mail]
4. Mailing address: 4601 East Oak Jsland Drive
City: Oak Island
State: NC Zip: 25465-501 l
5. Contact person: David Kelly II
Primary phone number: [phone] Select
Email: [e-mail]
Secondary phone number: [phone] Select
SECTION 11- FACILITY INFORMATION
L Physical address: 5406 E. Yacht Drive County; Brunswick Parcel No.: 2501 C001
City: Oak Island State: NC Zip: 28465-5011
2. Treatment facility coordinates to the sixth decimal degree:
Latitude: 33.1793331 Longitude:-78.108633° Method: Address matching
SECTION III - FLOW INFORMATION
1. Permitted flow: 400000 GPD (The maximum allowable flow based an what has been permitted)
2. As -built flow: 400000 GPD (7'he maximum allowableflow bosedon what has been constructed)
3. Average flaw: 80000 GPD (The average of all reporledflaws on the previous calendar year's XDMR.$)
4, Hydraulic achy: 20 % (Divide the averageflow in Item 3 by the .Qs -built flow in hem 2)
5. Wastewater composition: Domestic : 100 % Industrial Stormwater; %
SECTION IV -BILLING INFORMATION
1. Billing address: 464 I East Oak island Drive
City: Oak Island State: NC Zip: 28465-50 l 1
2. Verify the Applicant does not have any overdue annual fees:
https:fldeq.nc,itovi at�out}d i visions!water-reso�rcesfwater-r�saurc�s-permitsfwq-euaumen is
Pursuant to 1 SA NCAC 02T .0120[c}, pec-mits for renewing facilities shall not be granted if the Applicant or any affiliation has
an unpaid annual fee.
FORMRWS-R 02-21 Page 1 of 6

SECTION V — OPERATOR IN RESPONSIBLE CHARGE (ORQ INFORMATION
(NOT APPLICABLE FOP, WNSUNCTIVE SYSTEMS)
1. ORC: Bobby Steven Poarch Grade: W Certification No.: 12971
Mailing address: 4601 East Oak Island Drive
City: Oak Island State: NC Zip: 28465-5011
Phone number: [phone] Select Email: [e-mail]
2. Back -Up ORC: Kyle S. Brown Grade. 11 Certification No.. I1}10056
Mailing address: 4601 East Oak island Drive
City, Oak Island State: NC Zip: 28465-5011
Phone number; [phone] Select Email: fishfacturyrd@oakislandnc,gov
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 (gat)
Liner Type Freeboard (i)
Latitude Longitude
Select
250EC001
465,Oi14
Unlined 1
33.907777°-79.649720
Select 250EC001. 3I5.000 Unlined 1 33.907063"-78.66055"
Select Select 4 _ Q
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
Reclaimed Water
Upstream sewer
Select
Select
Select
Select
Select
Select
SECTION VUI — MONITORING WELLS
1. List all groundwater monitoring wells associated with the renewing permit. Attach additional sheets if necessary.
Well Name
Parcel No.
Status
Gradient
Lacation
Latitude
Longitude
l
250ECOOI
Active
❑owngradient
Inside Review Boundary
3.907003
-78.6641 i°
2
250ECO01
Active
Downgradient
inside Review Boundary
3.906672°
-78.661110
3
250ECOOI
Active
Upgradient
Inside Review Boundary
33.908ISO*
-78.64381"
select
Select
Select
_ °
- °
Select
Select
Select
Select
Select
Select
Seleel
Select
Select
select
Select
Select
°
°
Select
Select
Select
Select
Select
Select
FORM: RWS-R 02-21 Page 2 of

SECTION IX — UTILIZATION FIELDS
1. List all utilization fields associated with the renewing permit, Attach additional shcpts if necessary.
Field
County
Parcel No.
needed Owner
Area
Cover Crop
Latitude
Longitude
P
O
P
o
P
❑
P
�
OJ1
O
❑ J
- 9
❑
O
❑
9
O
O
❑
9
O
O
0
4
G
6
b
O
O
4
4
O
P
d �
9
O
a
a
4
O
❑
6
O
9
O
O
O
4
d
❑
O
❑
0
0
a
o
O
8
4
4
4
O
G
4
0
0
0
0
a
a
'dotal Acreage.
FORM: RWS-R 0z-2 1 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 AID5(d), submit a site map pursuant to the requirements in ISA NCAC_ 02U 0201(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 500 feet of the treatment, storage, and utilization areas.
❑ Soil mapping units shown on all utilization sites.
❑ Delineation of the compliance and review boundaries per 15A NCAC 02U .0501(a)(61.
L] Setbacks as required by 15A NCAC 02U _4701
Q Site property boundaries within 500 feet of all treatment, storage, and utilization 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 02T.0 106{c) authorizing the signature authority to sign.
ATTACHMENT C - FLOW REDUCTION I
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 flaw
contributed per unit for the 12 months prior to permit renewal If any of these Monthly averages are withip 20% of the
approved flow reduction value, the Permittee shall provide a reevaluation of the reduced flaw value pursuant to the
requirements in ISA NCAC 027 .01)4(f).
® No - Skip Attachment C.
ATTACHMENT D-CERTIF€CATE OF PUBLIC CONVENIENCE AND NECESSITY I
Is the Applicant a Privately -Owned Public Utility's
❑ Yes - Pursuant to 15A NCAC 02T ,01 Wa][ 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_
I ATTACHMENT E-OPERATIONAL AGREEMENT I
Is the Applicant a HomeRroperty Owners' Association or Developer of Lots to be Sold?
❑ Yes (HomelProperty Owners' Association) - Pursuant to 15A NCAC 02T .t}i 15fa)(21, submit an executed Operational
A greement FORM: HOA . Pursuant to 15A NCAC 02T .0115(c), if the applicant is a legally farmed 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 Astreern
(FORM. 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 E.
FORM: RWS-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 111, Item 4 exceed 70°Io?
❑ Yes (the hydraulic capacity is greater than 70%, but less than 800%) — Pursuant to 15A NCAC 02T _01 18(l 1, prior to exceeding
80 percent of the system's permitted hydraulic capacity (based on the average flow during the last calendar year), the perm ittee
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 reduttiottis_
❑ 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°10?
❑ Yes (the hydraulic capacity is greater than 80°10) — Pursuant to 15A NCAC 02T .0 11 82 , prior to exceeding 40 percent of the
system's permitted hydraulic capacity (based on the average flow during the last calendar year), the Mmittee 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 AGREEMENT'S
Does the Permittee own all of the land associated with the wastewater collection, treatment, conveyance, and utilization system?
❑ Yes — Skip Attachment O.
No — Pursuant to 15A NCAC 02T .01 16 0, provide a copy of all easements, lease agreements, and encroachment agreements
alkowing the Permittee to operate and maintain the wastewater collection, treatment, conveyance, and utilization system on
property not owned by the Permittee.
ATTACHMENT" — AFFILIATIONS
Are the Permittee's affiliations of record correct? Check affiliations.
® Yes — Skip Attachment H.
❑ Na — Provide the corrected affiliations and their contact information_
ATTACHMENT I — COMPLI.ANCE SCHEDULES
Does the existing petrnit include any Compliance Schedules? (See Section I of the mast recently issued permit)
❑ Yes — Submit documentation that the compliance schedules have been niet_
N No — Skip Attachment 1.
ATTACHMENT J — CIVIL PENALTIES AND OUTSTANDING VIOLATIONS
Does the Permittee have any existing Civil poRalties. or outstanding viplatipns9
❑ 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 3-
FORM: RWS-R 02-21 Page 5 of 6

ATTACHMENT K — INDUSTRIAL VVASTEWATER
Does the wastewater composition in Section 111, Item 5 include any industrial wastewater?
[I Yes — Proceed to the next question-
No — Skip Attachment K.
Has the nature of the industrial wastewater chan.-ed since the last permit issuance {i.e,, changes in industrial process, introduction
of new materials or chemicals, etc.}?
0 Yes — provide a chernicaJ analysis of the wastewater pursuant to the requirements in 15A NCAC 921J -0201( - 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?
E] Yes — Pursuant to 15A NCAC 02T .0701(p.), 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 .01 OT
No —Skip Attachment L.
APPLICANT'S CERTIFICATION I
that this
s name as noted in Section 1, item 3)
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 ,012g(b), that the applicant, ur
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, ar 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 snakes 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 S10,000 as well as civil penalties up to S25,O00 per violation.
Signature:
Date:
THE COMPLETED APPUGA-TION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE P>(]R; FILE VIA:
Email: Laserfiche Upload:
Nan-Discharge.Renorts(tnedenr.eov htt1)s:J/e4oes.dca.ne.i=-avIFnrms/NonDischarfe-Branch-
Sub rnittal-!♦ orm-Vert
FORM: RWS-R 02-21 Page 6 of 6

Dlvlslon of Water Resources
Mate of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0700 - HIGH -RATE INFILTRATION SYSTEM - RENEWAL
FORM: HRIS-R 02-21
Pursuant to 15A NCAC 02T A 07[bl, if the application does not include all required information and the necessary
sdpporting documentation, the application Shall be returned. The application and attachments shall be prepared in
acenrdance with 1 SA NCAC 027' .0100, 15,k NCAC if2T .0700, and DivWan Policies. For more informillion, visit the 'Water
Quality Permitting Section's Nan -Discharge Branch website. The Applicant shall submit an electronic copy 4f the application
and attachments uploaded as a single Portable Docgment Format (FDF) file to https:lledoes.deg.nc.tovlFvrmsfNonDisc harae-
Branch-Submittal-Form-Vert, or ern ailed to Non-D isc ba M. Re2o rtg& nedenr.gpv if less than 20 rnegabytes (MB).
SECTION I -APPLICANT INFORMATION
l .
Applicant: Town of Oak Island
2.
Permit No.: WQ0031857
3.
Signature authority: David Kelly It
Phone number: [phone] Select
Title: Town Manager
Email: [e-mail]
4.
Mailing address: 4601 East Oak I Bland Drive
City: Oak Island
State: NC Zip: 28465-5011
5.
Contact person: David Kelly 11
Primary phone number: [phone] Select
Email: dkelly( oakislandne.gov
Secondary phone number: [phone] Select
i SECTION II -FACILITY INFORMATION
1. Physical address: 5406 1_ Yacht Drive County: Brunswick Parcel No.: 236IH413
City: Oak Island State: KC Zip: 28465-521 L
2. Treatment facility coordinates to the sixth decimal degree:
Latitude: 33.919656' Longitude:-78,109613' Method. Address matching
SECTION III - FLOW INFORMATIONi
1. Permitted flow: 400000 GPD (The maximum allowable flow based on what has beer permitted)
2. As -built flow: 400000 GPD (The maximum allowable flow based on what has been conslrucled)
3. Average flow: 80000 OPD (?'he average of ail reported flows on the previous calendar year's NDUXk )
4, Hydraulic capacity- 20 % (Divide the average flow in item 3 by the As-buih flow in Item 2)
5. Wastewater cornpositiow Domestic: 100 % Industrial: % Stormwater: %
SECTION! IV - BILLING INFORMATION
1. Billing address: 4601 East Oak Island Drive
City: Oak Island State: NC Zip: 28465-521 I
2. Verify the Applicant does Aot have any overdue a<inual fees:
hags:lfdeq.nc.govfaboub'd i v isi oasfwager-resource slwater-resources-perm itslwq-ey�ym ents
Pursuant to 15A NCAC 02T ,4L2 c , permits for renewing facilities shall riot be granted if the Applicant or any affiliation has
an unpaid annual fee.
FORM: HRIS-R 02-21 Page L of 6

SECTION V -- OPERATOR IN RESPONSIBLE CHARGE (ORQ INFORMATION
1. ORC: Bobby Steven Poarch
Grade: IV Certification No.: 12971
Mailing address- 4601 Fast Oak Island Drive
City: Oak Island
State: NC Zip: 28465-5211
Phone number; [phone] Select
Email: spoarchgoakislandnc,gov
2. Back -Up ORC: Kyle S. Brown
Grade. lI Certification No_- I010456
Mailing address: 4601 East Oak Island Drive
City: Oak Island
State: NC Zip: 28465-5211
Phone number: [phone] Select
Email: fishfactoryrd@la oakisiandnc_gov
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 (t) Latitude
Longitude
Storage
250ECOOI
1 465,000 Unlined
1 33,907908°
-78.6497°
Storage 25DEC00I 315,(300 Unlined 1 33.907063"-78,6605°-
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
Reclaimed Water
Select
Select
Select
Select
Select
Select
Select
SIEMON VIII — MONITOICING WELLS
1, List all groundwater monitoring we11s associated with the renewing permit. ,A,rtach additional sheets if necessary.
Well Name
Parcel No.
Status
Gradient
Location
Latitude Longitude
1
250ECOOI
Active
Downgradient
Inside Review Boundary
3.9070030-78.6641°
2
250ECOOI
Active
Downgradien€
Inside Review Boundary
3.9066720 -78.661 l°
3
250ECOOI
Active
Upgradient
Inside Review Boundary
3,908150°-78.64381=
Select
Select
Select
4
°
Select
Select
Select
°
Select
Select
Select
4
°
5eloct
Select
Select
°
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
FORM: HRIS-R 02-21 Page 2 of 6

SECTION IX — INFILTRATION SITES
l _ List all infiltration sites associated with the renewing permit. Attach additional sheets if necessary.
Site
County
Parcel No.
Deeded Ownier
Area
Cover Crap
Lafitude
Lbrtgiliide
o
p
O
❑
4
a
b
❑
4
4
P
❑
P
4
P
4
P
4
❑
4
p
{}
4
p
6
4
p
4
a
❑
o
p
4
a
4
p
o
a
4
O
d
4
9
4
0
0
❑
4
o
a
a
a
o
a
a
a
a
a
o
a
D
6
4
a
a
v
a
a
D
O
Total Acreage:
FORM: HRIs-R 02.21 Page 3 of

ATTACHMENT A - SITE MAP
Was the facility originally permitted or had a major modification issued after September 1, 20%?
Yes - Pursuant to 15A NCAC 02T .0105(d), submit a site map pursuant to the requirements in ISA NCAC 02T .07044d).
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 aid fences within the wastewater treatment, storage, and infiltration areas.
p Sail 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_
❑ Delineation orthe compliance and review boundaries per 15A NQAC 02L .0107 and .0108_
M Setbacks as required by 15A NCAC 02T .0706.
❑ Site property boundaries within 500 feet of all wastewater treatment, storage, and infiltration sites.
p All habitable residences or places of public assembly within 500 feet of all treatment, storage, and infiltration sites.
❑ No - Skip Attachment A.
ATTACHMENT 0-SIGNATURE AUTHORITY DELEGATION
Does the signature authority in Section I, Item 3 meet the requirements pursuant to i 5A NCAC 02T .0106(b}?
Yes - Skip Attachment R.
❑ Ne - Submit a delegation letter pursuant to 15A. NCAC 02T .0l0f O authorizing the signature authority to sign.
ATTACHMENT C - FLOW REDUCTION I
Does the existing permit include an approved flow reduction's
❑ '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 she 12 months prior to permit renewal. If any of these monthly averages are within 20% of the
approved flaw reduction value, the Permittee shall provide a reevaluation of the reduced flow value pursuant to the
requirements in 15A NCAC 02T .0114(fj;
No - Skip Attachment C,
ATTACHMENT D - CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY I
Is the Applicant a Privately -Owned Pula]ic UtiIity?
❑ Yes - Pursuant to 15A 1NQAC 02T .01.t5(a1(1.), submit the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commission der onstrating the Applicant is authorized to hold the utility franchise.
® No - Skip Attachment D.
ATTACHMENT E -OPERATIONAL AGREEMENT
Is the Applicant a Homeftoperty Owners' Association or Developer of Lots to he Sold?
❑ Yes (Home/Property Owners' Association) - Pursuant to 15A NCAC 02T .t}115(a)(21, submit an executed Operational
Agreement (FORM: HOA}. Pursuant to 15A NCAC 02T .0115(cl, if the applicant is a legally formed Homeowners' or Property
Owners 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: DEVI. 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 E.
FORM: HRIS-R C2-21 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 700./c.7
❑ Yes (the hydraulic capacity is greater than 70%, but less than 80%) - pursuant to 15A NCAC 02-f .0l 1 E I , prior to exceeding
80 percent of the system's permitted bydraulic capacity (based on the average flow during the last calendar year), the perm ittee
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 steeds by either expansion of the existing
system, elimination or reduction of extraneous flaws, or water conservation and shall include the source of funding for the
improvements. If expansion is not proposed or is proposed for a later (late, a justification shall be made that wastewater
tmattment 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 809l0) - Proceed to the next question.
❑ No - Skip Attachment F.
If answered Yes above, does the Hydraulic capacity in Section IIJ, Item 4 exceed 8D%?
Q Yes (the hydraulic capacity is greater than 80%) - Pursuant to I5A NCAC 02T .0118['_), prior to exceeding 40 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 net proposed or is
proposed for a later date, a justification shall be made that wastewater treatment needs wiii he 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, ENCROACHNEENT, AND LEASE AGREEMENTS
Does the Permittee own all of the 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 ,0116(e), provide a copy of all easements, lease agreements, and encroachment agreements
allowing the Penn ittee to operate and maintain the wastewater coIlee iion, treatment, conveyance, infiltration, and grotrtdwater
lowering (if applicable) system on property not awned by the Pcimittee.
ATTACHMENT H - AFFILIATIONS
Are the Perrnittee's affiliations of record correct? Check affiliations.
❑ Yes •- Skip Attachment H.
❑ No - Provide the corrected affiliations and their contact inforrnaticm,
ATTACHMENT I - COMPLIANCE SCHEDULES
Does the existing permit include any Compliance Schedules? (See Section I of the mast recently issued pennit)
❑ Yes - Submit docurnontation that the compliance schedules have been met.
® No - Skip Attachment I.
ATTACHMENT J - CIVIL PENALTIES AND OUTSTANDING VIOLATIONS
Does the Perm ittee have any existing civil penalties or outstanding violations?
❑ Yes (civil penalties) - Submit payment for the civil penalty, or proof of remission request.
❑ Yes (violation-0 - Submit a copy of your response to the Notice of Violation.
® No - Skip Attachment J.
FORM: HILlS_R 02-21 Page 5 of

ATTACHMENT K -- INDUSTRIAL WASTEWATER
Does the wastewater composition in Section II1, Item 5 include any industrial wastewater?
❑ Yes - Proceed to the next question.
2 No - Skip Attachment K.
Has the mature 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{hl. 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
manufactunng process, and an overview ofthe cleaning and treatment methodology,
1 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 needs. Waivers involving the compliance boundary shall be in accordance
with 15A NCAC 02L .0107,
0 No - Skip Auachmerrt L.
APPLICANT'S CERTIFICATION I
that This appl
(Signature a�thority's name as noted in Section 1, Item 3)
has been reviewed by me and is accurate and complete to the best of my knowledge. 1 understand that if ail 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 .012D(h11 that the applicant, ar
any parent, subsidiary, or other affiliate of the applicant has: not been convicted of environmental crimes under, not previuusly
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 .01 Mb). An alternate person may be delegated
as the signing official if a letter is provided pursuant to 15A NCAC 02T .01061cl. Pursuant to § 143143-215,6A15.6A 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, whthmay include a fine not to exceed S 10,000 as well as civil penalties up to $25,Ofl0 per violation.
Signature-.
Date: l Wit i!:C
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDi; FILE VIA:
Email:
Non-Distharee.Reports(iE- nedenr.eov
Laserfiche Upload:
httos :1ledocs.deu . ne.govf Fo rm s!N Ga D isclf a rE�-Braneh-
Suhmittel-Farm-V€r2 --
FORM: HR1S-R 02-21 Page 6 uF6