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Home My WebLink AboutWQ0028693_Renewal_20190423State of North Carolina LIA .11 1 R Department of Environmental Quality UW Division of Water Resources NON-DISCHARGE SYSTEM RENEWAL, ' M%rlsion of Wier Rftourc" FORM: NDSR 02-19 This form is for renewal without modification for all non -discharge system permits, exceat Residuals Management and Single - Family Residence Wastewater Irrigation System permits. For more information, visit the Water Quality Permitting Section's Non-Discha ge.Branch. I. PERMITTEE INFORMATION: 1. Permittee: MQ(� 0 to A .S 2. Signature NCAC 02T Title:CTWLY-j '' COL UW authority's name: per .014_6[}i] Primary Telephone number: (_j _- Select Secondary number: (_} _- Select Email Address: 3. Permittee's mailing address: 5 A4 14 i (Yl-4 A) rpFQIp R City:u" State: JUL zip:aV_ REGEIVEp�� 4. Billing address (if different from above): APR 2 3 2019 City: State: Zip: - Non-Disch U e 5. Contact person's name (if different from signature authority): Title: Permitting it Primary Telephone number: (_} _- Select Secondary number: t�) _- Select Email Address: II. PERMIT INFORMATION: 1. Existing permit number: WQ00 �q,0 4? 3 2. Has the facility been constructed? Yes or ❑ No If yes, has the facility been constructed in accordance with the permit and the Division -approved plans and specifications? f 15A NCAC 02T .0114) 09 Yes or ❑ No If no, a formal permit modification request shall be submitted to the Division. 3. Has any of the property ownership within the facility and/or disposal area changed from what is indicated in the current permit (Attachment B — disposal field owner/lessee)? ❑ Yes or WNo Has the Permittee had a name change or has the permit changed ownership? ❑ Yes or OrNo If yes to either, a permit modification request shall be submitted to the Division. [ 15A NCAC 02T .0105] 4. Is this facility a Privately -Owned Public Utility? ❑ Yes or ]R No If yes, provide two copies ofthe 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. f 15A NCAC 02T .0I 15[a](1)] 5. Is the Permittee a Home/Property Owners' Associations or Developers of lots to be sold? X Yes or ❑ No If yes, provide the following: • For Home/Property Owners' Associations — Operational Agreement (,FORM: HOAR and a copy of the proposed or approved Articles of Incorporation, Declarations, and By-laws [ 15A NCAC 02T .0115i c: I • For Developers of lots to be sold — ORerational A ement f FORM: DEV . f i5A NCAC 02T .0115(b)] FORM: NDSR 02-19 Page 1 of 3 'DIvIslon of Wader Resources III. SITE MAP: State of North Carolina Department of Environmental Quality Division of Water Resources NON -DISCHARGE SYSTEM RENEWAL FORM: NDSR 02-19 1. Provide an updated site map in accordance with 15A NCAC 02T .0105(d) that shows the following: The site map is not required to be signed or sealed by a Professional Engineer. However, the map must indicate the source of information. For example, parcel lines taken from a county GIS map should reference the GIS website. ❑ Legend, north arrow, scale, and legible in black and white ❑ Topographic contour intervals not exceeding 10 feet or 25 percent of total site relief ❑ Soil mapping units on all disposal sites ❑ All facility -related structures and fences within the treatment, storage, and disposal areas ❑ All habitable residences and places of assembly within 500 feet of all treatment, storage, and irrigations sites ❑ Location of all wells, streams (ephemeral, intermittent, and perennial), springs, lakes, ponds, ditches, and other surface drainage features within 500 feet of all waste treatment, storage, and disposal site(s) ❑ Location and identification of each monitoring well (identify any backgmund/upgradient wells) ❑ Latitude and longitude coordinates of all monitoring wells (decimal degrees to 6 digits) ❑ Location and identification of major components of the waste disposal system ❑ The wetted perimeter of all irrigation fields with field names (named according to the approved permit) Q Location and ownership of property boundaries within 500 feet of the disposal area (including road/rail right-of-ways) ❑ The delineation of compliance and review boundaries ❑ Distance measurements verifying all setbacks are being met ❑ Stormwater drainage controls ❑ I00-year floodplain (if applicable) ❑ For reclaimed water ^eneration permits only. provide a separate map showing all distribution lines and utilization permit locations that are connected to the water generation facility and are permitted by the Non -Discharge Branch (excludes Local Program permitted facilities). Include all reclaimed water distribution line and reclaimed water utilization permit numbers. IV. SETBACK WAIVERS, EASEMENTS, AND LEASES: 1. Does the permit have any setback waivers, easements, or leases? a Yes oreNo If yes, provide copies of all documents and complete the table below: Document Type Grantor or Parcel No. Grantee Expiration Date County Deed Registered Book Deed Page Document Description I Select Select Select Select Select Select Select Select Select Select Select•- 1. The document description shall list any reduced setbacks with distance, etc. FORM: NDSR 02-19 Page 2 of 3 t _ State of North Carolina Department of Environmental Quality Division of Water Resources a � .,,91i8ro'a,..`O' NON -DISCHARGE SYSTEM RENEWAL I3tvision of Water Resources FORM: NDSR 02-19 V. RELATED PERMITS 1. If this permit has interactions with other wastewater permits (collection systems, NPDES, etc.), complete the table below (provide additional pages if necessary): Permit Tye Permit No. Description i I Applicant's Certification per 15A NCAC 02T .0106J)) : I, , attest that this renewal application has been reviewed by me, and is accurate and complete to the best of my knowledge. I understand that any unauthorized 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 should a condition of this permit be violated. I also understand that if all required parts of this application are not completed, this application may be returned to me as incomplete. I further certify that the Applicant or any parent, subsidiary, or other affiliate of the Applicant 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 does not have any overdue annual fees. NOTE — In accordance with General Statutes 1.43-215.6A 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. The Applicant's Certification shall be signed in accordance with 15A NCAC 02T .0106(b). Per 15A NCAC 02T .01�, an alternate person may be designated as the signing official if a delegation letter is provided fro person lo- eets the criteria in 15A NCAC 02T .0106(b) Signature: 1 ~ Date: 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-DISCEIARGE BRANCH By U.S. Postal Service: By Courier: By Email: Non -Discharge Branch Non -Discharge Branch — Archdale 640D Non-DiscliarQe.Reports ra.ncdenr.aov 1617 Mail Service Center 512 N. Salisbury St. Raleigh, NC 27699-1617 Raleigh, NC 27604 TELEPHONE NUMBER: (919) 707-3654 FORM: NDSR 02-19 Page 3 of 3 F.WSFulml�°gmsMounuin iop\Mli-wNkK-loo WELIS.tlxg, 411(101n t214A] vM 1:3U1.90C 6 N ro a z ry MHE E� � ® 1 _ _ r•t _ _r gong, °®+ ®® R. if gy aCrr d.n ado �~�� - ��•: �` • ^ ` i ��i n5 p��gga �F 3g��2-6�agg�bgg°• � $ � y $ F 6�5 s Rt 4!q ijlHil E R .ES 0 r r m c a _. g�,N 5IT y� $ _ ,O'o Digni d �s� �_ po z z m > Q 6 2"5 �{u5fF5\w�M4M�ManMin iop{Mf1-WeMG101 W¢Litlwg. L11ROI912AL14 DM L1Ul.Po9 4-4 o wo !! A a � 9�gF •®�� I ®:J ION n 5 g I .110.1i g Y 9^X2 B L 8 n E o p $ m ° m x IM m. a�a p s AE Z a a 7 01 0 CD M C-0 o Q x J � � � \ � MEW ■ | r|§ ■. \� '\ 'e e■| „ § §)h ■ 6A 1 ; § / § % 0 / ((i m q | « ; !-\f ` o $§ƒ \ k \ H \/( \])2 [ \ d e & 1111-111 .PI1 -A -A Hit 041 0 0 �'u MOBr 6 dw" mega A 2 5-- - FD' cn (n go G) > > Tm z i >* m, o 3 fn -j rrCD 0