WQ0035784_More Information (Received)_20240827

State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON-DISCHARGE PERMIT OWNERSHIP/NAME CHANGE
INSTRUCTIONS FOR FORM: NDPONC 06-16 & SUPPORTING DOCUMENTATION
INSTRUCTIONS FOR FORM: NDPONC 06-16 & SUPPORTING DOCUMENTATION Page 1 of 1
This form is for ownership changes or name changes of a non-discharge system permit. Please note that “Permittee”
references the existing permit holder, and that “Applicant” references the entity applying for the ownership/name change.
For more information, visit the Water Quality Permitting Section’s Non-Discharge Permitting Unit website
A.Non-Discharge Permit Ownership/Name Change (FORM: NDPONC 06-16) Application (All Applications):
Submit an original completed and appropriately executed Non-Discharge Permit Ownership/Name Change (FORM: NDPONC
06-16) application.
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 from 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.
C.Property Ownership Documentation (All Applications):
➢Per 15A NCAC 02T .0504(f), 15A NCAC 02T .0604(e), 15A NCAC 02T .0704(f), 15A NCAC 02T .0804, 15A NCAC 02T
.1004(d), 15A NCAC 02T .1104(d)(7), 15A NCAC 02T .1104(e)(5), 15A NCAC 02U .0201(e) or 15A NCAC 02U .0202(f),
the Applicant shall demonstrate they are the owner of all property containing the non -discharge system facilities:
Legal documentation of ownership (i.e., GIS, deed or article of incorporation), or
Written notarized intent to purchase agreement signed by both parties with a plat or survey map, or
Written notarized lease agreement that specifically indicates the intended use of the property and has been signed by both
parties, as well as a plat or survey map. Lease agreements shall adhere to the requirements of 15A NCAC 02L .0107.
D.Certificate of Public Convenience and Necessity (All Applications where the Applicant is a Privately-Owned Public Utility):
Per 15A NCAC 02T .0115(a)(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 franchise for the area to be served
by the non-discharge system.
E.Operational Agreements (All Applications where the Applicant is a Home/Property Owners' Association or Developer of lots to
be sold):
➢Home/Property 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.
➢Developers of lots to be sold
Per 15A NCAC 02T .0115(b), submit an original of the properly executed Operational Agreement (FORM: DEV).
F.Operation and Maintenance Agreement (All Applications for Single-Family Wastewater Irrigation Systems):
Per 15A NCAC 02T .0604(h), submit an original of a notarized Operation and Maintenance Agreement (FORM: SFRWWIS
O&M) that has been signed and dated by all deeded property owners.
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED TO:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON-DISCHARGE PERMITTING UNIT
By Courier/Special Delivery:
Non-Discharge Branch – Archdale 942W
512 N. Salisbury St.
Raleigh, NC 27604
Telephone Number: [phone]
By U.S. Postal Service:
Non-Discharge Branch
1617 Mail Service Center
Raleigh, NC 27699-1617

By Email:
[e-mail]
4
4
4
4
4
Docusign Envelope ID: FC694D80-EA34-4227-9B3E-986A347C7C41
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON-DISCHARGE PERMIT OWNERSHIP/NAME CHANGE
FORM: NDPONC 06-16
FORM: NDPONC 06-16 Page 1 of 2
I.EXISTING PERMITTEE INFORMATION:
per 15A NCAC 02T .0106(b) Title:
1.Permittee's name:
2.Signature authority’s name:
3.Permittee’s mailing address:
City:State:
4.Permittee’s contact information: Phone number: ()
-
-Email Address:
5.Demonstration of historical consideration for permit approval – 15A NCAC 02T .0120:
Has the Permittee or any parent, subsidiary or other affiliate exhibited the following?
a.Has been convicted of environmental crimes under Federal law or G.S. 143-215.6B? Yes or No
b.Has previously abandoned a wastewater treatment facility without proper ly closing that facility? Yes or No
c.Has unpaid civil penalty where all appeals have been abandoned or exhausted? Yes or No
d.Is non-compliant with an existing non-discharge permit, settlement agreement or order? Yes or No
e.Has unpaid annual fees in accordance with 15A NCAC 02T .0105(e)(2)? Yes or No
Zip: County:
and most recent issuance date:
II.FACILITY INFORMATION:
1.Facility name:
2.Facility’s physical address:
City:
III.PERMIT INFORMATION:
1.Existing permit number: WQ00
2.Existing permit type:
3.Reason for the permit application:
4.Has the facility been constructed? Yes or No
per 15A NCAC 02T .0106(b) Title:
IV.APPLICANT INFORMATION:
1.Applicant's name:
2.Signature authority’s name:
3.Applicant’s mailing address:
City:Zip: -
4.Applicant’s contact information: Phone number: () Email Address:
5.Demonstration of historical consideration for permit approval – 15A NCAC 02T .0120:
Has the Applicant or any parent, subsidiary or other affiliate exhibited the following?
a.Has been convicted of environmental crimes under Federal law or G.S. 143-215.6B? Yes or No
b.Has previously abandoned a wastewater treatment facility without proper ly closing that facility? Yes or No
c.Has unpaid civil penalty where all appeals have been abandoned or exhausted? Yes or No
d.Is non-compliant with an existing non-discharge permit, settlement agreement or order? Yes or No
e.Has unpaid annual fees in accordance with 15A NCAC 02T .0105(e)(2)? Yes or No
State:
-
Zip:
State:-
Wallace Loft LLC
Wen De Tam Director
5 Bryant Park, 28th Floor
New York NY 10018
646 908 6300 [e-mail]
4
4
4
4
4
The Cottages of Boone
615 Fallview Lane
Boone NC 28607 Watauga
35784 6/5/2023
Conjunctive Reclaimed Water Utilization
Change of Ownership
4
Boone Owner LLC
Andrew Stark Authorized Signatory
2 School St.
Rye NY 10,580
914 420 1171 [e-mail]
4
4
4
4
4
Docusign Envelope ID: FC694D80-EA34-4227-9B3E-986A347C7C41
FORM: NDPONC 06-16 Page 2 of 2
Existing Permittee's Certification per 15A NCAC 02T .0106(b):
I, attest that this application for
(Signature Authority’s name & title from Application Item I.2.)
(Facility name from Application Item II.1.)
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, any discharge of wastewater from this non-discharge system to surface waters or the land will result in an
enforcement action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim ag ainst 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 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 that the existing Permittee 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 penal ty where
all appeals have been exhausted or abandoned, are compliant with any active com pliance schedule, and do not have any overdue annual
fees per 15A NCAC 02T .0105(e).
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 fin e not to
exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature: Date:
Applicant's Certification per 15A NCAC 02T .0106(b):
I, attest that this application for
(Signature Authority’s name & title from Application Item IV.2.)
(Facility name from Application Item II.1.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that after reissuance of the permit
into the Applicant’s name, any discharge of wastewater from this non-discharge system to surface waters or the land will result in an
enforcement action that may include civil penalties, injunctive relief, and/or criminal pro secution. 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 informati on 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 env ironmental
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 per 15A
NCAC 02T .0105(e).
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:
Wen De Tam, Director
The Cottages of Boone
Andrew Stark, Authorized Signatory
The Cottages of Boone
8/24/2024
Docusign Envelope ID: FC694D80-EA34-4227-9B3E-986A347C7C41
28-Aug-2024 | 4:18 AM SGT