WQ0022785_Application_20240506

State of North Carolina
DWR
Department of Environmental Quality
. Division of Water Resources
Division of Water Resources 15A NCAC 02T .0500 —WASTEWATER IRRIGATION SYSTEM —RENEWAL
FORM: WWIS-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 be returned. The application and attachments shall be prepared in
accordance with 15A NCAC 02T .0100, 15A NCAC 02T .05009 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:/ledoes.de .nc. ov/Forms/NonDischa e-
Branch-Submittal-Form-Ver2, or emailed to Non-Discharue.Regortsnncdenr.gov if less than 20 megabytes (MB).
1. Applicant: L n+ 1 c W1 P (r [ril l/ o . �-A { t;F i n 1 n v, i 1 Irk'
12. Permit No.: WQ00
3. Signature authority: LZ)ro,�) � aCD�}S Title: DeDcon
Phone number: POW+ M Select Email:
4. Mailing address:
City: State: Zip: -
5. Contact person: L'1\21 :3 n 1 Email: rva+nlnooK(&bCe-nitw+ji i ft1G • r)c+-
Primary phone number: (gWP6p-21iySelect Secondary phone number: ( } - Select
1. Physical address: 110 � J I rn nn9 b-,k DA County: Oy'onof, Parcel No.:
CityjiuYdle Rills State: NC zip:����
2. Treatment facility coordinates to the sixth decimal degree:
Latitude: ° Longitude: - Method: Select
1. Permitted flow: GPD (The maximum allowable flow based on what has been permitted)
2. As -built flow: GPD (The maximum allowable flow based on what has been constructed)
3. Average flow: GPD (The average of all reported flows on the previous calendar year's NDMRs)
4. Hydraulic capacity: % (Divide the average flow in Item 3 by the As -built flow in Item 2)
5. Wastewater composition: Domestic: % Industrial: % Stormwater: %
FORM: WWIS-R 02-21 Page I of 6

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 (ft) Latitude Longitude
Select Select _
Select Select ° _
Select Select ° _
Select Select
f
k SECTIQN VIII 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
Select Select
Select
°
_ °
Select Select
Select
Select
Select
Select
°
_ °
Select
Select
Select
°
_ 0
Select
Select
Select
°
_ °
Select
Select
Select
°
_ °
Select
Select
Select
°
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°
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_
FORM: WWIS-R 02-21
Page 2 of 6

1. List all irrigation fields associated with the renewing permit. Attach additional sheets if necessary.
Field County Parcel No. Deeded Owner Area Cover Crop Latitude Longitude
o O
0 0
o 0
a o
O o
0 0
0 0
0 0
0 0
0 0
O o
0 0
0 0
0 0
O O
O O
O O
O 0
O O
O O
O O
0 a
0 0
0 0
0 0
0 0
O 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
o a
0 0
Total Acreage:
FORM: WW1S-R 02-21 Page 3 of 6

Was the facility originally permitted or had a major modification issued after September 1, 2006?
❑0 requ
irements Pursuant
esuants 15A NCAC 02T .0105(d, submit a site map pursuant to the requirements in I5A NCAC 02T .0504(d),
❑ 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 irrigation areas.
❑ Soil mapping units shown on all irrigation 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 irrigation sites.
❑ Delineation of the compliance and review boundaries per 15A NCAC 02L .0I 07 and .0108, and 15A NCAC 02T .0506(c)
if applicable.
❑ Setbacks as required by 15A NCAC 02T .0506.
❑ Site property boundaries within 500 feet of all wastewater treatment, storage, and irrigation sites.
❑ All habitable residences or places of public assembly within 500 feet of all treatment, storage, and irrigation sites.
❑❑ No — Skip Attachment A.
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 1.5A NCAC 02T .0106(c) authorizing the signature authority to sign.
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.
Is the Applicant a Privately -Owned Public Utility? ❑
❑❑ Yes — Pursuant to 15A NCAC 02T .0115(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.
Is the Applicant a Home/Property Owners' Association or Developer of Lots to be Sold? ❑
❑❑ Yes (Home/Property Owners' Association) — Pursuant to 15A NCAC 02T .0115(a)(2), submit an executed Operational
Agreement FORM: HOA . Pursuant to 15A NCAC 02T .0115(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 Operational Agreement
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: WWIS-R 02-21 Page 4 of 6

VATTACHMENT F DEMONSTRATIQN'F FUTUR>; WASTEWATER TREATMENT CAPACITI(hS
thelicant a municipality, county, sanitary district, or public utility?
s — Proceed to the next question.
— 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 .0118 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 80%) — 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.
Does the Permittee own all of the land associated with the wastewater collection, treatment, conveyance, and irrigation system?
❑❑ Yes — Skip Attachment G.
❑❑ No — Pursuant to 15A_NCAC 02T .0116(c), provide a copy of all easements, lease agreements, and encroachment
agreements allowing the Permittee to operate and maintain the wastewater collection, treatment, conveyance, and irrigation
system on property not owned by the Permittee.
Are the Permittee's affiliations of record correct? Check affiliations.
❑❑ Yes — Skip Attachment H.
❑❑ No — Provide the corrected affiliations and their contact information.
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.
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: WWIS-R 02-21 Page 5 of 6

ATTACHIVIENT K INDUSTRIAL 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 .0504(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.
Does the existing permit include setback waivers?
❑❑ Yes —Pursuant to 15A NCAC 02T .0506 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.
L.cyo taco �s
attest that this applicatic
(Signature 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 misdemc jor, which rn include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature:
Date: 5 d 5 H 2—DZ
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email:
Non-Discharge.Reports{a,ncdenr.gov
Laserfiche Upload:
htt s://edocs.de .nc. ov/Forms/NonDischar e-Branch-
Submittal-Form-Vert
FORM: VMS-R 02-21
Page 6 of 6