WQ0012948_More Information Received_20241011

Initial Review
Reviewer
nathaniel.thornburg
Is this submittal an application? (Excluding additional information.) *
Yes No
If not an application what is the submittal type?* Annual Report
Residual Annual Report
Additional Information
Other
Permit Number (IR) * W00012948
Applicant/Permittee North Carolina Wildlife Resources Commission
Email Notifications
Does this need review by the hydrogeologist? * Yes No
Regional Office
CO Reviewer
Admin Reviewer

Submittal Form
Project Contact Information
Please provide information on the person to be contacted by NDB Staff regarding electronic submittal, confirmation of receipt, and other correspondence.
......................................................................................................................................................................................................................................................................................... ... ... ... ... ... .. ... ... ... ... ..
Name* Timothy Sheehan
Email Address*
[e-mail]
Project Information
.........................
Application/Document Type*
New (Fee Required)
Modification - Major (Fee Required)
Renewal with Major Modification (Fee
Required)
Annual Report
Additional Information
Other
Phone Number*
7044431391
Modification - Minor
Renewal
GW-59, NDMR, NDMLR, NDAR-1,
N DAR-2
Residual Annual Report
Change of Ownership
We no longer accept these monitoring reports through this portal. Please click on the link below and it will take you to the correct form.
https://edoes.deq.nc.gov/Forms/NonDischarge_Monitoring_Report
Permit Type:* Wastewater Irrigation High -Rate Infiltration
Other Wastewater Reclaimed Water
Closed -Loop Recycle Residuals
Single -Family Residence Wastewater Other
Irrigation
Permit Number:* WQ0012948
Has Current Existing permit number
Applicant/Permittee Address* 1720 Mail Service Center Raleigh, NC 27699-1720
Facility Name* Pisgah Center for Wildlife Education WWTF
Please provide comments/notes on your current submittal below.
Updated WWIS 06-16 form with correct signature authority provided per Cord Anthony request.
At this time, paper copies are no longer required. If you have any questions about what is required, please contact Nathaniel Thornburg
at [e-mail].
Please attach all information required or requested for this submittal to be reviewed here.
(Application Form, Engineering Plans, Specifications, Calculations, Etc.)
WWIS 06-16 (On -Site WW Treatment System).pdf 793.19KB
Upload only 1 PDF document (less than 250 MB). Multiple documents must be combined into one PDF file unless file is larger
than upload limit.
* By checking this box, I acknowledge that I understand the application will not be accepted for pre -review until the fee (if required) has
been received by the Non -Discharge Branch. Application fees must be submitted by check or money order and made payable to the
North Carolina Department of Environmental Quality (NCDEQ). I also confirm that the uploaded document is a single PDF with all parts
of the application in correct order (as specified by the application).
Mail payment to:
NCDEQ — Division of Water Resources
Attn: Non -Discharge Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Signature
Submission Date 10/11/2024

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0500 — WASTEWATER IRRIGATION SYSTEMS
Division of Water Resources INSTRUCTIONS FOR FORM: WWIS 06-16 & SUPPORTING DOCUMENTATION
Plans, specifications and supporting documents shall be prepared in accordance with 15A NCAC 02H .0400 (if necessary), 15A
NCAC 02L .0100. 15A NCAC 02T .0100, 15A NCAC 02T .0700, Division Policies and sood ensineerins practices. Failure to
submit all required items will necessitate additional processing and review time.
For more information, visit the Water Quality Permitting Section's Non -Discharge Permittine Unit website
General — When submitting an application to the Water Quality Permitting Section's Non -Discharge Permitting Unit, please use the
following instructions as a checklist in order to ensure all required items are submitted. Adherence to these instructions and checking
the provided boxes will help produce a quicker review time and reduce the amount of requested additional information.
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation.
A. Cover Letter (All Application Packages):
E List all items included in the application package, as well as a brief description of the requested permitting action.
B. Application Fee (All New and Major Modification Application Packages):
❑ Submit a check, money order or electronic funds transfer made payable to: North Carolina Department of Environmental
Quality (NCDEQ). The appropriate fee amount for new and major modification applications may be found at: Standard Review
Proiect Fees.
C. Wastewater Irrigation Systems (FORM: WWIS 06-16) Application (All Application Packages):
® Submit the completed and appropriately executed Wastewater Irrigation Systems (FORM: WWIS 06-16) application. Any
unauthorized content changes to this form shall result in the application package being returned. If necessary for clarity or due
to space restrictions, attachments to the application may be made, as long as the attachments are numbered to correspond to the
section and item to which they refer.
❑ If the Applicant Type in Item L2. is a corporation or company, provide documentation it is registered for business with the
North Carolina Secretary of State.
❑ If the Applicant Type in Item L2. is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of Deeds in
the county of business.
❑ The facility name in Item IL 1. shall be consistent with the facility name on the plans, specifications, agreements, etc.
® The Professional Engineer's Certification on Page 12 of the application shall be signed, sealed and dated by a North Carolina
licensed Professional Engineer.
® The Applicant's Certification on Page 12 of the application 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).
❑ If this project is for a renewal without modification, use the Non -Discharge Svstem Renewal (FORM: NDSR) application.
D. Property Ownership Documentation (All Application Packages):
➢ Per 15A NCAC 02T .0504(f), the Applicant shall demonstrate they are the owner of all property containing the wastewater
treatment, storage and irrigation 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.
❑ Provide all agreements, easements, setback waivers, etc. that have a direct impact on the wastewater treatment, conveyance,
storage and irrigation facilities.
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E. Soil Evaluation (All Application Packages that include new irrigation sites):
❑ Per 15A NCAC 02T .0504(b) and the Soil Scientist Evaluation Policv, submit a detailed soil evaluation that has been signed,
sealed and dated by a North Carolina Licensed Soil Scientist and includes at a minimum:
❑ The report shall identify all the sites/fields with project name, location, and include a statement that the sites/fields were
recommended for the proposed land application activity.
❑ Field delineated detailed soils map meeting all of the requirements of the Soil Scientist Evaluation Policv.
❑ Soil profile descriptions meeting all of the requirements of the Soil Scientist Evaluation Policv.
❑ Provide all soil boring logs performed at the site.
❑ Standard soil fertility analysis conducted no more than one year prior to permit application for each map unit in the soil
map legend for the following parameters:
❑ Acidity ❑ Exchangeable sodium percentage (by calculation) ❑ Phosphorus
❑ Base saturation (by calculation) ❑ Magnesium ❑ Potassium
❑ Calcium ❑ Manganese ❑ Sodium
❑ Cation exchange capacity ❑ Percent humic matter ❑ Zinc
❑ Copper ❑ pH
➢ Saturated hydraulic conductivity (KSAT) data that shall include at a minimum:
❑ A minimum of three KsAT tests shall be conducted in the most restrictive horizon for each soil series in the soil map.
❑ All KsAT tests shall be conducted in areas representative of the site.
❑ All KsAT tests shall be run until steady-state equilibrium has been achieved.
❑ All collected KsAT data shall be submitted, including copies of field worksheets showing all collected readings.
❑ Submit a soil profile description for each KsAT data point that shall extend at least one foot below the tested horizon.
➢ Soil evaluation recommendations shall include at a minimum:
❑ A brief summary of each map unit and its composition and identification of minor contrasting soils.
❑ Maximum irrigation precipitation rate (in/hr) for each soil/map unit within the proposed irrigation areas.
❑ Seasonal irrigation restrictions, if appropriate.
❑ Identification of areas not suitable for wastewater irrigation.
❑ Recommended geometric mean KsAT rate to be used in the water balance for each soil/map unit based upon in -situ
measurement of the saturated hydraulic conductivity from the most restrictive horizon.
❑ Recommended drainage coefficient to be used in the water balance based upon comprehensive site evaluation, review
of collected onsite data, minor amounts of contrasting soils and the nature of the wastewater to be applied.
❑ Recommended annual hydraulic loading rate (in/yr) for each soil/map unit within the proposed irrigation areas based
upon in -situ KsAT measurements form the most restrictive soil horizon.
NOTE — If the soil evaluation was performed more than one year prior to the submittal of this application package, a statement shall
be included indicating that the site has not changed since the original investigation.
F. Agronomist Evaluation (All Application Packages that include new irrigation sites or new crops for existing irrigation sites):
❑ Per 15A NCAC 02T .0504(i), submit an agronomist evaluation that has been signed, sealed and dated by a qualified professional
and includes at a minimum:
❑ Proposed nutrient uptake values for each cover crop based upon each field's dominant soil series and percent slope.
❑ Plant available nitrogen calculations for each cover crop using the designed effluent concentrations in Application Item
V.1. and proposed mineralization and volatilization rates.
❑ Historical site consideration, soil binding and plant uptake of phosphorus.
❑ Seasonal irrigation restrictions, if appropriate.
❑ A clear and reproducible map showing all areas investigated and their relation to proposed fields and crops.
❑ Maintenance and management plan for all specified crops.
INSTRUCTIONS FOR FORM: WWIS 06-16 & SUPPORTING DOCUMENTATION Page 2 of 6

G. Hydrogeologic Report (All Application Packages treating industrial waste or having a design flow over 25,000 GPD):
❑ Per 15A NCAC 02T .0504(e), the Hvdro2eolo2ic Investigation and Reporting Policv, the Groundwater Modeling Policv and
the Performance and Analvsis of Aquifer Slue Tests and Pumping Tests Policv, submit a detailed hydrogeologic description
that has been signed, sealed and dated by a qualified professional and includes at a minimum:
❑ A hydrogeologic description to a depth of 20 feet below land surface or bedrock, whichever is less. A greater depth of
investigation is required if the respective depth is used in predictive calculations.
❑ Representative borings within the irrigation areas and all proposed earthen impoundments.
❑ A description of the regional and local geology and hydrogeology.
❑ A description, based on field observations of the site, of the site topographic setting, streams, springs and other groundwater
discharge features, drainage features, existing and abandoned wells, rock outcrops, and other features that may affect the
movement of the contaminant plume and treated wastewater.
❑ Changes in lithology underlying the site.
❑ Depth to bedrock and occurrence of any rock outcrops.
❑ The hydraulic conductivity and transmissivity of the affected aquifer(s).
❑ Depth to the seasonal high water table (SHWT).
❑ A discussion of the relationship between the affected aquifers of the site to local and regional geologic and hydrogeologic
features.
❑ A discussion of the groundwater flow regime of the site prior to operation of the proposed facility and post operation of
the proposed facility focusing on the relationship of the system to groundwater receptors, groundwater discharge features,
and groundwater flow media.
❑ If the SHWT is within six feet of the surface, a mounding analysis to predict the level of the SHWT after wastewater
application.
H. Water Balance (All Application Packages that include new or modified irrigation sites, changes in flow or changes in storage):
❑ Per 15A NCAC 02T .0504(k) and the Water Balance Calculation Policv, submit a water balance that has been signed, sealed
and dated by a qualified professional and includes at a minimum:
❑ At least a two-year iteration of data computation that considers precipitation into and evaporation from all open atmosphere
storage impoundments, and uses a variable number of days per month.
❑ Precipitation based on the 80' percentile and a minimum of 30 years of observed data.
❑ Potential Evapotranspiration (PET) using the Thornthwaite method, or another approved methodology, using a minimum
of 30 years of observed temperature data.
❑ Soil drainage based on the geometric mean of the in -situ KsAT tests in the most restrictive horizon and a drainage coefficient
ranging from 4 to 10% (unless otherwise technically documented).
➢ Other factors that may restrict the hydraulic loading rate when determining a water balance include:
❑ Depth to the SHWT and groundwater lateral movement that may result in groundwater mounding.
❑ Nutrient limitations and seasonal application times to ensure wastewater irrigation does not exceed agronomic rates.
❑ Crop management activities resulting in cessation of irrigation for crop removal.
NOTE — Wastewater Irrigation Systems serving residential facilities shall have a minimum of 14 days of wet weather storage.
I. Engineering Plans (All Application Packages):
® Per 15A NCAC 02T .0504(c)(1). submit standard size and 11 x 17-inch plan sets that have been signed, sealed and dated by a
North Carolina licensed Professional Engineer, and shall include at a minimum:
❑ Table of contents with each sheet numbered.
® A general location map with at least two geographic references and a vicinity map.
❑ A process and instrumentation diagram showing all flow, recycle/return, aeration, chemical, electrical and wasting paths.
® Plan and profile views of all treatment and storage units, including their piping, valves, and equipment (i.e., pumps,
blowers, mixers, diffusers, flow meters, etc.), as well as their dimensions and elevations.
® Details of all piping, valves, pumps, blowers, mixers, diffusers, recording devices, fencing, auxiliary power, etc.
❑ A hydraulic profile from the treatment plant headworks to the highest irrigation point.
❑ The irrigation area with an overlay of the suitable irrigation areas depicted in the Soil Evaluation.
❑ Each nozzle/emitter and their wetted area influence, and each irrigation zone labeled as it will be operated.
❑ Locations within the irrigation system of air releases, drains, control valves, highest irrigation nozzle/emitter, etc.
❑ For automated irrigation systems, provide the location and details of the precipitation/soil moisture sensor.
® Plans shall represent a completed design and not be labeled with preliminary phrases (e.g., FOR REVIEW ONLY, NOT
FOR CONSTRUCTION, etc.) that indicate they are anything other than final specifications. However, the plans may be
labeled with the phrase: FINAL DESIGN - NOT RELEASED FOR CONSTRUCTION.
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Specifications (All Application Packages):
® Per 15A NCAC 02T .0504(c)(2), submit specifications that have been signed, sealed and dated by a North Carolina licensed
Professional Engineer, and shall include at a minimum:
® Table of contents with each section/page numbered.
❑ Detailed specifications for each treatment/storage/irrigation unit, as well as all piping, valves, equipment (i.e., pumps,
blowers, mixers, diffusers, flow meters, etc.), nozzles/emitters, precipitation/soil moisture sensor (if applicable),
audible/visual high water alarms, liner material, etc.
® Site Work (i.e., earthwork, clearing, grubbing, excavation, trenching, backfilling, compacting, fencing, seeding, etc.)
® Materials (i.e., concrete, masonry, steel, painting, method of construction, etc.)
❑ Electrical (i.e., control panels, transfer switches, automatically activated standby power source, etc.)
❑ Means for ensuring quality and integrity of the finished product, including leakage, pressure and liner testing.
® Specifications shall represent a completed design and not be labeled with preliminary phrases (e.g., FOR REVIEW ONLY,
NOT FOR CONSTRUCTION, etc.) that indicate they are anything other than final specifications. However, the
specifications may be labeled with the phrase: FINAL DESIGN - NOT RELEASED FOR CONSTRUCTION.
K. Engineering Calculations (All Application Packages):
® Per 15A NCAC 02T .0504(c)(3), submit engineering calculations that have been signed, sealed and dated by a North Carolina
licensed Professional Engineer, and shall include at a minimum:
❑ Hydraulic and pollutant loading calculations for each treatment unit demonstrating how the designed effluent
concentrations in Application Item V.1. were determined.
❑ Sizing criteria for each treatment unit and associated equipment (i.e., blowers, mixers, flow meters, pumps, etc.).
❑ Total and effective storage calculations for each storage unit.
❑ Friction/total dynamic head calculations and system curve analysis for each pump used.
❑ Manufacturer's information for all treatment units, pumps, blowers, mixers, diffusers, flow meters, irrigation system, etc.
® Flotation calculations for all treatment and storage units constructed partially or entirely below grade.
❑ A demonstration that the designed maximum precipitation and annual loading rates do not exceed the recommended rates.
❑ A demonstration that the specified auxiliary power source is capable of powering all essential treatment units.
L. Site Map (All Application Packages):
® Per 15A NCAC 02T .0504(d), submit standard size and 11 x 17-inch site maps that have been signed, sealed and dated by a
North Carolina licensed Professional Engineer and/or Professional Land Survevor, and shall include at a minimum:
® 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 .0107 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.
NOTE — For clarity, multiple site maps of the facility with cut sheet annotations may be submitted.
M. Power Reliability Plan (All Application Packages):
® Per 15A NCAC 02T .0505(1), submit documentation of power reliability that shall consist of at a minimum:
® An automatically activated standby power supply onsite that is capable of powering all essential treatment units under
design conditions, OR
➢ Approval from the Director that the facility:
❑ Serves a private water distribution system that has automatic shut-off during power failures and has no elevated water
storage tanks,
❑ Has sufficient storage capacity that no potential for overflow exists, and
❑ Can tolerate septic wastewater due to prolonged detention.
INSTRUCTIONS FOR FORM: WWIS 06-16 & SUPPORTING DOCUMENTATION Page 4 of 6

N. Operation and Maintenance Plan (All Application Packages):
❑ Per 15A NCAC 02T .0507, submit an operation and maintenance (O&M) plan encompassing all wastewater treatment, storage
and irrigation systems that shall include at a minimum a description of:
❑ Operation of the wastewater treatment, storage and irrigation systems in sufficient detail to show what operations are
necessary for the system to function and by whom the functions are to be conducted.
❑ Anticipated maintenance of the wastewater treatment, storage and irrigation systems.
❑ Safety measures, including restriction of access to the site and equipment.
❑ Spill prevention provisions such as response to upsets and bypasses, including how to control, contain and remediate.
❑ Contact information for plant personnel, emergency responders and regulatory agencies.
NOTE — A final O&M Plan shall be submitted with the partial and/or final Engineering Certification required under 15A NCAC
02T .0116, however, a preliminary O&M Plan shall be submitted with each application package.
O. Residuals Management Plan (All Application Packages with new, expanding or replacement wastewater treatment systems):
❑ Per 15A NCAC 02T .0504(i) and .0508, submit a Residuals Management Plan that shall include at a minimum:
❑ A detailed explanation of how generated residuals (including trash, sediment and grit) will be collected, handled, processed,
stored, treated, and disposed.
❑ An evaluation of the treatment facility's residuals storage requirements based upon the maximum anticipated residuals
production rate and ability to remove residuals.
❑ A permit for residuals utilization or a written commitment to the Applicant from a Permittee of a Department approved
residuals disposal/utilization program that has adequate permitted capacity to accept the residuals or has submitted a
residuals/utilization program application.
❑ If oil/grease removal and collection are a designed unit process, submit an oil/grease disposal plan detailing how the
oil/grease will be collected, handled, processed, stored and disposed.
NOTE — Per 15A NCAC 02T .0505(o), a minimum of 30 days of residual storage shall be provided.
NOTE — Per 15A NCAC 02T .0504(i), a written commitment to the Applicant from a Permittee of a Department approved residuals
disposal/utilization program is not required at the time of this application, however, it shall be provided prior to operation of any
permitted facilities herein.
NOTE — If an on -site restaurant or other business with food preparation is contributing wastewater to this system, an oil/grease
disposal plan shall be submitted.
P. Additional Documentation:
➢ Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .0115(a)(1) and .0504(g), provide 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 wastewater treatment and irrigation system, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an
application for a franchise has been received and that the service area is contiguous to an existing franchised area or that
franchise approval is expected.
➢ Existing Permit (All Modification Packages):
® Submit the most recently issued existing permit.
❑ Provide a list of any items within the permit the Applicant would like the Division to address during the permit modification
(i.e., compliance schedules, permit description, monitoring, permit conditions, etc.).
➢ Final Environmental Document (All Application Packages using public monies or lands subject to the North Carolina
Environmental Policy Act under 15A NCAC 01 C .0100 to .0400):
❑ Per 15A NCAC 02T .0105(c)(4), submit one copy of the environmental assessment and three copies of the final
environmental document (i.e., Finding of No Significant Impact or Record of Decision).
❑ Include information on any mitigating factors from the Environmental Assessment that impact the design and/or
construction of the wastewater treatment and irrigation system.
➢ Floodway Regulation Compliance (All Application Packages where any portion of the wastewater treatment, storage and
irrigation system is located within the 100-year floodplain):
❑ Per 15A NCAC 02T .0105(c)(8), provide written documentation from all local governing entities that the facility is in
compliance with all local ordinances regarding construction or operation of wastewater treatment and/or disposal facilities
within the floodplain.
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P. Additional Documentation (continued):
➢ Operational Agreements (All Application Packages for Home/Property Owners' Associations and Developers of lots to be
sold):
➢ Home/Provertv Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Aareement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit the proposed or approved Articles of Incorporation, Declarations and By-laws.
➢ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Aareement (FORM: DEV).
➢ Threatened or Endangered Aquatic Species Documentation (All Application Packages):
❑ Per 15A NCAC 02T .0105(c)(10), submit documentation from the Department's Natural Heritage Program demonstrating
the presence or absence of threatened or endangered aquatic species within the boundary of the wastewater treatment,
storage and irrigation facilities.
❑ If the facility directly impacts such species, this documentation shall provide information on the need for permit conditions
pursuant to 15A NCAC 02B .0110.
➢ Wastewater Chemical Analysis (All Application Packages treating Industrial Waste):
❑ Per 15A NCAC 02T .0504(h), provide a complete Division certified laboratory chemical analysis of the effluent to be
irrigated for the following parameters (For new facilities, an analysis from a similar facility's effluent is acceptable):
❑ Ammonia Nitrogen (NH3-N) ❑ Nitrate Nitrogen (NOs-N) ❑ Total Organic Carbon
❑ Calcium ❑ pH ❑ Total Phosphorus
❑ Chemical Oxygen Demand (COD) ❑ Phenol ❑ Total Trihalomethanes
❑ Chloride ❑ Sodium ❑ Total Volatile Organic Compounds
❑ Fecal Coliform ❑ Sodium Adsorption Ratio (SAR) ❑ Toxicity Test Parameters
❑ 5-day Biochemical Oxygen Demand (BOD5) ❑ Total Dissolved Solids
❑ Magnesium ❑ Total Kjeldahl Nitrogen (TKN)
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 U.S. Postal Service:
1617 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1617
TELEPHONE NUMBER: [phone]
By Courier/Special Deliverv:
512 N. SALISBURY ST.
RALEIGH. NORTH CAROLINA 27604
FAX NUMBER: [phone]
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State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
15A NCAC 02T .0500 — WASTEWATER IRRIGATION SYSTEMS
Division of Water Resources FORM: WWIS 06-16
I. APPLICANT INFORMATION:
1. Applicant's name: North Carolina Wildlife Resources Commission
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ® State ❑ Municipal ❑ County
3. Signature authority's name: Adam Moticak per 15A NCAC 02T .0106(b) Title: Fish Hatchery Superintendent
4. Applicant's mailing address: 1720 Mail Service Center
City: Raleigh State: NC Zip: 27699-1720
5. Applicant's contact information:
Phone number: [phone] Email Address: Adam.Moticak(a-),ncwildlife.ora
II. FACILITY INFORMATION:
1. Facility name: Bobbv N. Setzer State Fish Hatchery
2. Facility status: Existing
3. Facility type: Minor (< 10,000 GPD or < 300 disposal acres)
4. Facility's physical address: 1401 Fish Hatchery Road
City: Pisgah Forest State: NC Zip: 28768- County: Transvlvania
5. Wastewater Treatment Facility Coordinates (Decimal Degrees): Latitude: 35.282500' Longitude:-82.798900'
Datum: Unknown Level of accuracy: Unknown Method of measurement: Unknown
6. USGS Map Name:
III. CONSULTANT INFORMATION:
1.
Professional Engineer: Timothv Sheehan License Number: 019891 Firm: McGill Associates
Mailing address: 55 Broad Street
City: Asheville State: NC
Zip: 28801-
Phone number: [phone]
Email Address: tim.sheehan(&mcgillassociates.com
2.
Soil Scientist:
License Number: Firm:
Mailing address:
City: State:
Zip: -
Phone number: (_) =
Email Address:
3.
Geologist:
License Number: Firm:
Mailing address:
City: State:
Zip: -
Phone number: (_) =
Email Address:
4.
Agronomist:
Firm:
Mailing address:
City: State:
Zip: -
Phone number: (_) =
Email Address:
FORM: WWIS 06-16 Page 1 of 12

IV. GENERAL REQUIREMENTS — 15A NCAC 02T .0100:
1. Application type: ❑ New ❑ Major Modification ® Minor Modification
If a modification, provide the existing permit number: WQ0012948 and most recent issuance date: August 18, 2020
2. Application fee: $0 - Standard - Minor Modification
3. Does this project utilize public monies or lands? ® Yes or ❑ No
If yes, was an Environmental Assessment required under 15A NCAC 01 C? ❑ Yes or ® No
If yes, which final environmental document is submitted? ❑ Finding of No Significant Impact or ❑ Record of Decision
Briefly describe any mitigating factors from the Environmental Assessment that may impact this facility:
4. What is the status of the following permits/certifications applicable to the subject facility?
Permit/Certification Date Date Permit/Certification Agency Reviewer
Submitted Approved Number
Collection Svstem (O > 200,000 GPD)
Dam Safetv
Erosion & Sedimentation Control Plan
Nationwide 12 / Section 404
Pretreatment
Sewer Svstem
Stormwater Management Plan
Wetlands 401
Other:
5. What is the wastewater type? ® Domestic or ] Industrial (See 15A NCAC 02T .0103(20)1
Is there a Pretreatment Program in effect? ❑ Yes or ❑ No
�i Has a wastewater chemical analysis been submitted? ❑ Yes or ❑ No
6. Wastewater flow: 7500 GPD
Limited by: ® Treatment, ❑ Storage, ❑ Field Hydraulics, ❑ Field Agronomics or ❑ Groundwater Mounding
7. Explain how the wastewater flow was determined: ❑ 15A NCAC 02T .0114 or ® Representative Data
Has a flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes or ® No
Establishment Type Daily Design Flow a No. of Units Flow
Eduction center employees per shift (septic tank 25 gal/Day 13 325 GPD
1, 2000 gallon)
Houses (3 bedroom) (septic tank 1, 2000 Gallon) 360 gal/Day 3 1080 GPD
Education Building Students (septic tank 1, 2000
10 gal/Day 25 250 GPD
gallon)
Public Restroom Water closets (septic tank 2, 325 gal/Day 6 1950 GPD
5000 Gallon)
gal/ GPD
gal/ GPD
Total 3605 GPD
a See 15A NCAC 02T .0114(b). (d), (e)(1) and (e)(2), for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use areas;
and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S. 42A-4).
FORM: WWIS 06-16 Page 2 of 12

IV. GENERAL REQUIREMENTS —15A NCAC 02T .0100 (continued):
8. What is the nearest 100-year flood elevation to the facility? 2341.4 feet mean sea level. Source: Survevor
Are any treatment, storage or irrigation facilities located within the 100-year flood plain? ® Yes or ❑ No
If yes, which facilities are affected and what measures are being taken to protect them against flooding?
All Openings
Lipd 2' above BFE.
If yes, has the Applicant submitted written documentation of compliance with � 143 Article 21 Part 6? ® Yes or ❑ No
9. Has the Applicant provided documentation of the presence or absence of threatened or endangered aquatic species utilizing
information provided by the Department's Natural Heritage Program? ❑ Yes or ® No
10. Does the facility have a proposed or existing groundwater monitoring well network? ❑ Yes or ® No
If no, provide an explanation as to why a groundwater monitoring well network is not proposed: Not part of
plans or existing
permit
If yes, complete the following table (NOTE — This table may be expanded for additional wells):
Well Name Status Latitude a Longitude a Gradient
Location
Select 0- Select
Select
Select 0- Select
Select
Select 0- Select
Select
Select 0- Select
Select
Select 0- Select
Select
Select 0- Select
Select
Select 0- Select
Select
Select 0- Select
Select
Select 0- Select
Select
Select 0- Select
Select
a Provide the following latitude and longitude coordinate determination information:
Datum: Select Level of accuracy: Select Method of measurement: Select
11. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been submitted?
❑ Yes, ❑No or ®N/A
12. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been submitted?
❑ Yes, ❑No or ®N/A
13. If the Applicant is a Home/Property Owners' Association, has an Association Operational Agreement (FORM: HOA) been
submitted? ❑ Yes, ❑No or ®N/A
14. 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. 143-215.613? ❑ Yes or ® No
b. Has previously abandoned a wastewater treatment facility without properly 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
FORM: WWIS 06-16 Page 3 of 12

V. WASTEWATER TREATMENT FACILITY DESIGN CRITERIA — 15A NCAC 02T .0505:
1. For the following parameters, provide the estimated influent concentrations and designed effluent concentrations as
determined in the Engineering Calculations, and utilized in the Agronomic Evaluation and Groundwater Modeling (if
applicable):
Parameter
Ammonia Nitrogen (NH3-N)
Biochemical Oxygen Demand (BOD5)
Fecal Coliforms
Nitrate Nitrogen (NO3-N)
Nitrite Nitrogen (NO2-N)
Total Kjeldahl Nitrogen
Total Nitrogen
Total Phosphorus
Total Suspended Solids (TSS)
Estimated Influent Concentration
45 mg/L
250 mg/L
VW MW
10 mg/L
0 mg/L
55 mg/L
<10 mg/L
120 mg/L
Designed Effluent Concentration
(monthly average)
5 mg/L
15 mg/L
1000 per 100 mL
10 mg/L
5 mg/L
10 mg/L
25 mg/L
5 mg/L
15 mg/L
2. Is flow equalization of at least 25% of the average daily flow provided? ® Yes or ❑ No
3. Does the treatment facility include any bypass or overflow lines? ❑ Yes or ® No
If yes, describe what treatment units are bypassed, why this is necessary, and where the bypass discharges:
4. Are multiple pumps provided wherever pumps are used? ® Yes or ❑ No
If no, how does the Applicant intend on complying with 15A NCAC 02T .0505(k)?
5. Check the appropriate box describing how power reliability will be provided in accordance with 15A NCAC 02T .0505(1):
® Automatically activated standby power supply onsite capable of powering all essential treatment units; or
❑ Approval from the Director that the facility:
➢ Has a private water supply that automatically shuts off during power failures and does not contain elevated water
storage tanks;
➢ Has sufficient storage capacity that no potential for overflow exists; and
➢ Can tolerate septic wastewater due to prolonged detention.
6. If the wastewater treatment system is located within the 100-year flood plain, are there water -tight seals on all treatment units
or a minimum of two feet protection from the 100-year flood plain elevation? ® Yes, ❑ No or ❑ N/A
7. In accordance with 15A NCAC 02T .0505(o). how many days of residuals storage are provided? >30
8. How does the Applicant propose to prohibit public access to the wastewater treatment and storage facilities? fencing
9. If an influent pump station is part of the proposed facility (i.e., within the wastewater treatment plant boundary), does the
influent pump station meet the design criteria in 15A NCAC 02T .0305(h)? ❑ Yes, ❑ No, ❑ N/A — To be permitted
separately, or ® N/A — Gravity fed
10. If septic tanks are part of the wastewater treatment facility, do the septic tanks adhere to the standards in 15A NCAC 18A
1900? ® Yes, ❑ No or ❑ N/A
FORM: WWIS 06-16 Page 4 of 12

V. WASTEWATER TREATMENT FACILITY DESIGN CRITERIA — 15A NCAC 02T .0505 (continued):
11. Provide the requested treatment unit and mechanical equipment information:
a.
PRELIMINARY / PRIMARY TREATMENT (i.e., physical removal operations and flow equalization):
No. of Manufacturer or Dimensions (ft) / Volume
Plan Sheet
Specification
Treatment Unit
Units Material Spacings (in) (gallons)
Reference
Reference
Septic Tank 1 Precast Concrete 6'-0"Wxl6'-0"Lx8'-0" 5000
C-220
03330
High
Septic Tank 1 Precast Concrete 5'-0"WXIO-0"Lx6'- 2000
C-220
03330
4"High
Select
Select
Select
b.
SECONDARY / TERTIARY TREATMENT (i.e., biological and chemical processes to remove
organics and
nutrients)
No. of Manufacturer or Volume
Plan Sheet
Specification
Treatment Unit Dimensions (ft)
Units Material (gallons)
Reference
Reference
Select 2 t
Select
Select
Select
Select
Select
Select
Select
c.
DISINFECTION
No. of Manufacturer or Volume
Plan Sheet
Specification
Treatment Unit Dimensions (ft)
Units Material (gallons)
Reference
Reference
Select
Select
➢
If chlorination is the proposed method of disinfection, specify detention time provided:
minutes (NOTE
— 30
minutes minimum required), and indicate what treatment unit chlorine contact occurs:
➢
If ultraviolet (UV) light is the proposed method of disinfection, specify the number of banks:
number
of lamps
per bank: and maximum disinfection capacity: GPM.
d.
RESIDUAL TREATMENT
No. of Manufacturer or Volume
Plan Sheet
Specification
Treatment Unit Dimensions (ft)
Units Material (gallons)
Reference
Reference
Select
Select
FORM: WWIS 06-16 Page 5 of 12

V. WASTEWATER TREATMENT FACILITY DESIGN CRITERIA — 15A NCAC 02T .0505 (continued):
e. PUMPS
Location No. of Purpose Manufacturer / Capacity Plan Sheet Specification
Pumps Type GPM TDH Reference Reference
f. BLOWERS
Location
g. MIXERS
Location
No. of
Blowers
No. of
Mixers
Units Served
Units Served
Manufacturer /
Type
Manufacturer /
Type
h. RECORDING DEVICES & RELIABILITY
Device No. of Location Manufacturer
Units
Select
Select
Select
Select
i. EFFLUENT PUMP / FIELD DOSING TANK (IF APPLICABLE):
Capacity Plan Sheet Specification
(CFM) Reference Reference
Power Plan Sheet Specification
(hp) Reference Reference
Maximum Plan Sheet Specification
Capacity Reference Reference
FORM: WWIS 06-16 Page 6 of 12

Internal dimensions (L x W x H or (p x H)
Total volume
Dosing volume
Audible & visual alarms
Equipment to prevent irrigation during rain
events
ft I ft ft
ft3 gallons
ft3 gallons
Plan Sheet Specification
Reference Reference
FORM: WWIS 06-16 Page 7 of 12

VI. EARTHEN IMPOUNDMENT DESIGN CRITERIA — 15A NCAC 02T .0505:
IF MORE THAN ONE IMPOUNDMENT, PROVIDE ADDITIONAL COPIES OF THIS PAGE AS NECESSARY.
1. What is the earthen impoundment type? Select
2. Storage Impoundment Coordinates (Decimal Degrees): Latitude: 0Longitude: - °
Datum: Select Level of accuracy: Select Method of measurement: Select
3. Do any impoundments include a discharge point (pipe, spillway, etc)? ❑ Yes or ❑ No
4. Are subsurface drains present beneath or around the impoundment to control groundwater elevation? ❑ Yes or ❑ No
5. Is the impoundment designed to receive surface runoff? ❑ Yes or ❑ No
If yes, what is the drainage area? ft', and was this runoff incorporated into the water balance? ❑ Yes or ❑ No
6. If a liner is present, how will it be protected from wind driven wave action?:
7. Will the earthen impoundment water be placed directly into or in contact with GA classified groundwater? ❑ Yes or ❑ No
If yes, has the Applicant provided predictive calculations or modeling demonstrating that such placement will not result in a
contravention of GA groundwater standards? ❑ Yes or ❑ No
8. What is the depth to bedrock from the earthen impoundment bottom elevation? ft
If the depth to bedrock is less than four feet, has the Applicant provided a liner with a hydraulic conductivity no greater than
1 x 10-' cm/s? ❑ Yes, or ❑ N/A
Has the Applicant provided predictive calculations or modeling demonstrating that surface
water or groundwater standards will not be contravened? ❑ Yes or ❑ No
If the earthen impoundment is excavated into bedrock, has the Applicant provided predictive calculations or modeling
demonstrating that surface water or groundwater standards will not be contravened? ❑ Yes, ❑ No or ❑ N/A
9. If the earthen impoundment is lined and the mean seasonal high water table is higher than the impoundment bottom
elevation, how will the liner be protected (e.g., bubbling, groundwater infiltration, etc.)?
10. If applicable, provide the specification page references for the liner installation and testing requirements:
11. If the earthen impoundment is located within the 100-year flood plain, has a minimum of two feet of protection (i.e., top of
embankment elevation to 100-year flood plain elevation) been provided? ❑ Yes or ❑ No
12. Provide the requested earthen impoundment design elements and dimensions:
Earthen Impoundment Design Elements Earthen Impoundment Dimensions
Liner type: ❑ Clay I ❑ Synthetic Top of embankment elevation: ft
❑ Other ❑ Unlined
Liner hydraulic conductivity: x - cm/s Freeboard elevation: ft
Hazard class: Select Toe of slope elevation: ft
Designed freeboard: ft Impoundment bottom elevation: ft
Total volume: ft3 gallons Mean seasonal high water table depth: ft
Effective volume: ft3 gallons Embankment slope:
Effective storage time: days Top of dam water surface area: ft2
Plan Sheet Reference: Freeboard elevation water surface area: ft2
Specification Section: Bottom of impoundment surface area: ft2
NOTE — The effective volume shall be the volume between the two foot freeboard elevation and the: (1) pump intake pipe
elevation; (2) impoundment bottom elevation or (3) mean seasonal high water table, whichever is closest to the two foot
freeboard elevation.
FORM: WWIS 06-16 Page 8 of 12

VIL IRRIGATION SYSTEM DESIGN CRITERIA — 15A NCAC 02T .0505:
1. Provide the minimum depth to the seasonal high water table within the irrigation area:
NOTE — The vertical separation between the seasonal high water table and the ground surface shall be at least one foot.
2. Are there any artificial drainage or water movement structures (e.g., surface water or groundwater) within 200 feet of the
irrigation area? ❑ Yes or ❑ No
If yes, were these structures addressed in the Soil Evaluation and/or Hydrogeologic Report, and are these structures to be
maintained or modified?
3. Soil Evaluation recommended loading rates (NOTE — This table may be expanded for additional soil series):
Recommended Recommended Annual /Seasonal If Seasonal, list
Soil Series Fields within Loading Rate Loading Rate appropriate
Soil Series (in/hr) (in/yr) Loading months
Select
Select
Select
Select
Select
Select
4. Are the designed loading rates less than or equal to Soil Evaluation recommended loading rates? ❑ Yes or ❑ No
If no, how does the Applicant intend on complying with 15A NCAC 02T .0505(n)?
5. How does the Applicant propose to prohibit public access to the irrigation system?
6. Has the irrigation system been equipped with a flow meter to accurately determine the volume of effluent applied to each
field as listed in VIL8.? ❑ Yes or ❑ No
If no, how does the Applicant intend on complying with 15A NCAC 02T .0505(t)?
7. Provide the required cover crop information and demonstrate the effluent will be applied at or below agronomic rates:
Cover Crop Soil Series % Slope Nitrogen Uptake Rate Phosphorus Uptake
(lbs/ac•yr) Rate (lbs/ac•yr)
a. Specify where the nitrogen and phosphorus uptake rates for each cover crop were obtained:
b. Proposed nitrogen mineralization rate:
c. Proposed nitrogen volatilization rate:
d. Minimum irrigation area from the Agronomist Evaluation's nitrogen balance: ft2
e. Minimum irrigation area from the Agronomist Evaluation's phosphorus balance: ft2
f. Minimum irrigation area from the water balance: ft2
FORM: WWIS 06-16 Page 9 of 12

VIL IRRIGATION SYSTEM DESIGN CRITERIA — 15A NCAC 02T .0505 (continued):
8. Field Information (NOTE — This table may be expanded for additional fields):
Designed Designed
Area Dominant LoadingLoading Waterbody
Field g Latitude a Longitude a Stream Index Classification
(acres) Soil Series Rate Rate
(in/hr) (in/yr) No.
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 _ 0
a Provide the following latitude and longitude coordinate determination information:
Datum: Select Level of accuracy: Select Method of measurement: Select
b For assistance determining the waterbody stream index number and its associated classification, instructions may be
downloaded at: httn://dea.ne.aov/about/divisions/water-resource s/Dlannina/classification-standards/classifications
Spray Irrigation Design Elements Drip Irrigation Design Elements
Nozzle wetted diameter: ft Emitter wetted area: ft2
Nozzle wetted area: ft2 Distance between laterals: ft
Nozzle capacity: GPM Distance between emitters: ft
Nozzle manufacturer/model: / Emitter capacity: GPH
Elevation of highest nozzle: ft Emitter manufacturer/model: /
Specification Section: Elevation of highest emitter: ft
Specification Section:
FORM: WWIS 06-16 Page 10 of 12

VIIL SETBACKS — 15A NCAC 02T .0506:
1. Does the project comply with all setbacks found in the river basin rules (15A NCAC 02B .0200)? ® Yes or ❑ No
If no, list non -compliant setbacks:
2. Have any setback waivers been obtained in order to comply with 15A NCAC 02T .506(a) and .0506 ? ❑ Yes or ® No
If yes, have these waivers been written, notarized and signed by all parties involved and recorded with the County Register of
Deeds? ❑ Yes or ❑ No
3. Provide the minimum field observed distances (ft) for each setback parameter to the irrigation system and treatment/storage
units (NOTE — Distances greater than 500 feet may be marked N/A):
Setback Parameter
Any habitable residence or place of assembly under separate ownership or not to be
maintained as part of the project site
Any habitable residence or place of assembly owned by the Permittee to be maintained as
part of the project site
Any private or public water supply source
Surface waters (streams — intermittent and perennial, perennial waterbodies, and wetlands)
Groundwater lowering ditches (where the bottom of the ditch intersects the SHWT)
Subsurface groundwater lowering drainage systems
Surface water diversions (ephemeral streams, waterways, ditches)
Any well with exception of monitoring wells
Any property line
Top of slope of embankments or cuts of two feet or more in vertical height
Any water line from a disposal system
Any swimming pool
Public right of way
Nitrification field
Any building foundation or basement
Impounded public water supplies
Public shallow groundwater supply (less than 50 feet deep)
Irrigation Treatment /
System Storage Units
N/A
N/A
219
;N/A
N/A
4. Does the Applicant intend on complying with 15A NCAC 02T .0506(c) in order to have reduced irrigation setbacks to
property lines? ❑ Yes or ® No
If yes, complete the following table by providing the required concentrations as determined in the Engineering Calculations
Estimated Influent
Designed Effluent
Designed Effluent
Parameter
Concentration
Concentration
Concentration
(monthly average)
(daily maximum)
Ammonia Nitrogen (NH3-N)
mg/L
mg/L
mg/L
Biochemical Oxygen Demand
mg/L
mg/L
mg/L
(BODs)
Fecal Coliforms
per 100 mL
per 100 mL
Total Suspended Solids (TSS)
mg/L
mg/L
mg/L
Turbidity
NTU
FORM: WWIS 06-16 Page 11 of 12

IX. COASTAL WASTE TREATMENT DISPOSAL REQUIREMENTS — 15A NCAC 02H .0400:
1. Is this facility located in a Coastal Area as defined per 15A NCAC 02H .0403? ❑ Yes or ® No
For assistance determining if the facility is located within the Coastal Area, a reference map may be downloaded at: Coastal
Areas Boundarv.
2. Is this an Interim Treatment and Disposal Facility per 15A NCAC 02H .0404(a)? ❑ Yes or ® No
NOTE — Interim facilities do not include County and Municipal area -wide collection and treatment systems.
IF ANSWERED YES TO ITEMS IX.1. AND IX.2., THEN COMPLETE ITEMS IX.3. THROUGH IX.17.
3. Is equalization of at least 25% of the average daily flow provided? ❑ Yes or ❑ No
4. How will noise and odor be controlled?
5. Is an automatically activated standby power source provided? ❑ Yes or ❑ No
6. Are all essential treatment units provided in duplicate? ❑ Yes or ❑ No
NOTE — Per 15A NCAC 02T .0103(16), essential treatment units are defined as any unit associated with the wastewater
treatment process whose loss would likely render the facility incapable of meeting the required performance criteria, including
aeration units or other main treatment units, clarification equipment, filters, disinfection equipment, pumps and blowers.
7. Are the disposal units (i.e., irrigation fields) provided in duplicate (e.g., more than one field)? ❑ Yes or ❑ No
8. Is there an impounded public surface water supply within 500 feet of the wetted area? ❑ Yes or ❑ No
9. Is there a public shallow groundwater supply (less than 50 feet deep) within 500 feet of the wetted area? ❑ Yes or ❑ No
10. Is there a private groundwater supply within 100 feet of the wetted area? ❑ Yes or ❑ No
11. Are there any SA classified waters within 100 feet of the wetted area? ❑ Yes or ❑ No
12. Are there any non -SA classified waters within 50 feet of the wetted area? ❑ Yes or ❑ No
13. Are there any surface water diversions (i.e., drainage ditches) within 25 feet of the wetted area? ❑ Yes or ❑ No
14. Per the requirements in 15A NCAC 02H .0404(2)(7), how much green area is provided? ft2
15. Is the green area clearly delineated on the plans? ❑ Yes or ❑ No
16. Is the sprav irritation wetted area within 200 feet of any adjoining properties? ❑ Yes, ❑ No or ❑ N/A (i.e., drip irrigation)
17. Does the designed annual loading rate exceed 91 inches? ❑ Yes or ❑ No
FORM: WWIS 06-16 Page 12 of 12

Professional Engineer's Certification::( { �
I, �I m a-RY — t l ft �i attest that this application for
(Professional Engineer's name from Application Item I11.1.)
(Facility name from Application Item II.1.)
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 knowledge. I further attest that to the best of my knowledge the
proposed design has been prepared in accordance with this application package and its instructions, as well as al] applicable regulations
and statutes. 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 with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.08, 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,
North Carolina Professional Engineer's seal, signature, and date:
ps
H
,.
sr
�oove�ne�
Applicant's Certification per 15A NCAC 021' .0106fb):
attest that this application for
(Signature Authority's name & title from Application Item 1.3.)
(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 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. 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 per l5A NCAC 02T .0105(c).
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: /Z) ✓/f xo 2 Al
FORM: W W IS 06-16 Page 13 of 12