WQ0044401_Application_20240603

State of North Carolina
Department of )environmental Quality
Division of Water Resources
W-R SEWER SYSTEM PERMIT OWNERSHIP/NAME CHANGE
Division of Water Resources INSTRUCTIONS FOR FORM: PNOCF 01-16
This form is for ownership changes or name changes of a sewer system permit. Please note that "Permittee" references the
existing permit holder, and that "Applicant" references the entity applying for the ownership/name change.
Sewer permits start with a WQ or WQCS and contain the terms sewer extension or collection system in the subject field. This
form should not be used for permits with NC, NCG, SW or other types of non -sewer permits beginning with WQ.
For more information, visit the Division's Yflater Quality Permitting's website:
A. Sewer System Permit Ownership/Name Change (.FORM: PNOCF 01-16) Application (All Applications):
® Submit an original completed and appropriately executed application (PNOCF 01-16).
® The Existing Permittee's Certification shall be signed in accordance with 15A NCAC 02T .0106 b . Per 15A NCAC 02T
.0106 c , an alternate person may be designated as the signing official if a delegation letter is provided fi•om a person who
meets the criteria in 15A NCAC 02T .0106(b).
® The Applicant's Certification shall be signed in accordance with 15A NCAC 02T .0106 b . Per 15A NCAC 02T .0106(c), an
alternate person may be designated as the signing official if a delegation letter is provided from a person who meets the criteria
in 15A NCAC 02T .0106 b .
B. Existing Permit (All Applications):
® Submit a copy of the most recently issued permit and certification.
C. Property Ownership Documentation (All Applications):
➢ The Applicant shall demonstrate they are the owner of all property containing the sewer system facilities:
® Legal documentation of ownership (i.e., GIS, deed, article of incorporation, or contract), or
® Written notarized intent to purchase agreement signed by both parties with a plat or survey map, or
❑ Approved board minutes
D. Certificate of Public Convenience and Necessity (All Applications where the Applicant is a Privately -Owned Public Utility):
(� Per 15A NCAC 02T .01 15a 1 , provide one copy of the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility fi•anchise for the area to be served
by the non -discharge system.
E. Operational Agreements (Applications where the Applicant is a Home/Property Owners' Association or Developer of lots to be
sold):
N/A ➢ Home/Pro ert Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit an original properly executed Operational Agreement (FORM: HOA .
❑ Per 15A NCAC 02T .0115(c), submit an original proposed or approved Articles of Incorporation, Declarations and By-
laws that contain the language required by the Operational Agreement.
➢ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit an original of the properly executed operational Agreement f FORM: DEV .
F. Papkage Submitted in Duplicate
[( Submit a copy of all required documents in Instructions A-E as required
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED IN DUPLICATE
TO:
NCDEQ - DWR
Water Quality Permitting Section
PERCS Unit
D, U.S. Postal Service: B► Courier/SLecial Deliver:
1617 MAIL SERVICE CENTER 512 N. SALISBURY ST.
RALEIGH, NORTH CAROLINA 27699-1636 SUITE 925
RALEIGH, NORTH CAROLINA 27604
TELEPHONE NUMBER: [phone]
INSTRUCTIONS FOR APPLICATION PNOCF 01-16 Page 1 of 1

State of North Carolina
Department of Environmental Quality
Division of Water Resources
_ SEWER SYSTEM PERMIT OWNERSHIP/NAME CHANGE
INSTRUCTIONS FOR FORM: PNOCF 01-16
Division of Water Resources
I. EXISTING PERMITTEE INFORMATION:
1, Permittee's name: North State Development, LLC
2. Signature authority's name: Shane Seagle per 15A NCAC 02T .0106(b)
3. Signature authority's title: Managing Member
4. Permittee's mailing address: 18825 W. Catawba Ave Suite 250
City: Cornelius State: NC Zip: 28031-_
5. Permittee's contact information: Phone number: [phone] Fax Number (_) _-
Email Address: sseagle cr nortlistatedevelopment.com
II. APPLICANT INFORMATION:
1. Applicant's name: Catawba Villw,,e Owner. LLC
2. Signature authority's name: John Inch Jr. per 15A NCAC 02T .0106(b)
3. Signature authority's title: ManaZing Member
4. Applicant's mailing address: 2950 Lewisberry Road
City: York State: PA Zip: 17404-
5. Applicant's contact information: Phone number: [phone] Fax Number (_)
Email Address: ii»cliiKtiD.inchaudco.com
6. Representative's name: Sam Saxton
7. Representative's title: Development Coordinator
8. Representative's contact information Phone number: [phone] Fax Number (_)
Email Address: ssaxton _ incliandco.com
III. PERMIT INFORMATION:
1. Existing permit number: W }0044401 and most recent issuance date: June 2. 2023_
2. Reason for the permit application: Change of Ownership If other, attach detailed explanation
3. Has the facility been constructed? ❑ Yes or ® No
4. Has the facility been certified per 15A NCAC 02T .0116? ❑ Yes or ® No
FORM: PNOCF 01-16 Page 1 of

IV. CERTIFICATIONS:
Existing Permittee's Certification per 15A NCAC 02T .0106(b}:
I Shane Seagle, Manager of North State Development attest that this application
(Signature Authority's name & title from Application Item I.2 & 3)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that prior to reissuance of the permit
into the Applicant's name, I will continue to be responsible for compliance with the current permit and any discharge of wastewater
from this system to surface waters or the land may result in an enforcement action that may include civil penalties, injunctive relief,
and/or criminal prosecution. I will also make no claim against the Division of Water Resources should a condition of the existing permit
be violated. I also understand that if all required parts of this application are note completed and that if all required supporting
information and attachments are not included, this application will be returned to me as incomplete.
NOTE — In accordance with General Statutes 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, which may include a fine not to
exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature:
Date: `2/26/2024
Applicant's Certification per 15A NCAC 02T .0106(b):
I,Joho Y .n Mern&r attest that this application
(Signature Authority's name & title fi•om Application Item I1.2&3.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that after issuance of the permit into
the Applicant's name, I will be responsible for compliance with the issued permit and any discharge of wastewater from this non -
discharge system to surface waters or the land may result in an enforcement action that may include civil penalties, injunctive relief,
and/or criminal prosecution. I will make no claim against the Division of Water Resources shoulda. 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.
NOTE — In accordance with General Statutes 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, which may include a fine not to
exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature:
Date: G)-La( 1
FORM: PNOCF 01-16 Page 2 of 2

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02L the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria latest version as applicable?
® Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
concurrently with the approval of the vermit, and proiects requiring a variance approval may be subject to longer
review times. For proiects re uiri two or more variances or where the variance is determined by the Division to be a
significant portion of the oroiect, the full technical review is required.
2. Professional Engineer's Certification: A
ro
I, , attest that this application for %AWIA
(Pssional Engin is name from A plication Item IlI.1.) (Project Name from Application Item ILI)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations, and all other supporting documentation to the best of my krosvledge. I further
attest that to the best of my knowledge the proposed design has been prepared in accordance with the applicable regulations,
Minimum Design Criteria for Gravity Sewers ( latest version), and the Minimum Desi Criteria for the Fast Track Pefinitti v
of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to be consistent %dth the proposed design. ,
NOTE — In accordance with General Statutes 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 S10,000, as well as civil penalties up to $25,000 per violation. Misrepresentation of the application
information, including failure to disclose any design non-compliance x«th the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date:
SEAL
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3_ Applicant's Certification per 15A NCAC 02T .0106(b):
I, _ John I I [ i Jr- , _ attest that this application for CATQ %(/ V 1114cje,
(Signature Authority Name from Application Item I.3.) (Project Name from Applicati tem II.1)
attest that this application 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 are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. 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 Resources 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.
NOTE — In accordance with General Statutes 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: 2
FORM: FTA 10-23 Page 5 of 5