WQ0034220_Application_20200511

State of North Carolina
WR Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
Division of Water Resources FORM: NDSR 01-20
This form is for renewal without modification for all non -discharge system permits, except Residuals Management and Single -
Family Residence Wastewater Irrigation System permits.
For niore information, visit the Water Quality Permitting Section's Non -Discharge Branch Website.
01
I. PERMITTEE INFORMATION: RECEIVED
l . Permittee: ai.1-v-CL ArsS 0 By Nathaniel Thornburg at 8:43 am, May 11, 2020
2. Signature authority's name: ier 15A NCAC 02T .0106(b) Title:
Primary Telephone number: (a) 6z- 1 l►1 Select Secondary number: (_) = Select
Email Address: _S94&T 1, `S n4 kl, !. %lA50. "eJ-
3. Permittee's mailing address: F c, 6 ® )c $6,1 A,
City: p_e�(- State: t.J; L Zip:
4. Billing address (if different from above): fet,w�e.
City: State: Zip: -
5. Contact person's name (if different from signature authority): Me Title:
Primary Telephone number: (_) = Select Secondary number: (� _- Select
Email Address:
II. PERMIT INFORMATION:
1. Existing permit number: WQ00 -; 4'12,0
2. Has the facility been constructed? ❑ Yes or RNo
If yes, has the facility been constructed in accordance with the permit and the Division -approved plans and specifications?
[15A NCAC 02T ,O 1101 ❑ 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 [ %
Has the Permittee had a name change or has the permit changed ownership? ❑ Yes or [ o
If yes to either, a permit modification request shall be submitted to the Division. [15A NCAC 02T .01051
4. Is this facility a Privately -Owned Public Utility? 0Yes or F?(No
If yes, provide two copies of the Certificate of Public Convenience and Necessity from the North Carolina Utilities Commission
demonstrating the Applicant is authorized to hold the utility franchise. [15A NCAC 02T .01 15(a)(1)1
5. Is the Permittee a Home/Property Owners' Associations or Developers of lots to be sold? ❑ Yes or [rNo
If yes, provide the following:
For Home/Property Owners' Associations - Operational Agreement (FORM: HOA) and a copy of the proposed or
approved Articles of Incorporation, Declarations, and By-laws [15A NCAC 02T .01 15(c)l
® For Developers of lots to be sold - Operational Agreement (FORM: DEV) [15A NCAC 02T .01.15(b)]
FORM: NDSR 01-20 Page 1 of 4

Division of Water Resources
6. Does the facility treat and dispose of industrial wastewater? t40
If yes, complete items below. If no, skip to the next section.
Indicate the approximate percentage of wastewater makeup:
Industrial: % Domestic: % Stormwater: %
State of Forth Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 01-20
For all industrial wastewater sources (excluding those permitted under a pretreatment permit), provide a detailed industrial
process description including:
• An overview of the manufacturing process
• An inventory of all materials used for manufacture, including chemicals and biological matter
• An overview of cleaning and treatment methodology, including an inventory of treatment materials and compounds
Has the nature of wastes (e.g., change in industrial processes, introduction of new materials or chemicals, etc.) described in the
approved permit application(s) changed? ❑ Yes or ❑ No
If yes, a permit modification request shall be submitted to the Division. [G.S. 141-215.1(d)]
III. SITE MAP:
1. Provide an updated site map in accordance with 15A NCAC 02T .0105(d) that shows the following (if applicable):
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, and scale
❑ Topographic contours on all disposal sites
❑ 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)
❑ 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)
❑ 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
❑ 100-year floodplain
❑ For reclaimed water generation permits, 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.
FORM: NDSR 0 1 -20 Page 2 of 4

Division of Water Resources
IV. GROUNDWATER MONITORING WELLS
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 01-20
1. Does the facility have a proposed or existing groundwater monitoring well network? ❑ Yes or ["No
If no, skip to next section.
If yes, complete the following table (NOTE — This table may be expanded for additional wells):
Well Name
Status
Latitude
Longitude
Gradient
Location
Select
0-0
Select
Select
Select
0-0
Select
Select
Select
0-0
Select
Select
Select
0-0
Select
Select
Select
0-0
Select
Select
Select
0-0
Select
Select
Select
0-0
Select
Select
Select
0-0
Select
Select
Select
0-0
Select
Select
Select
0-C,Select
Select
a. Coordinates must be in NAD83 and have 6 decimal degrees
V. SETBACK WAIVERS, EASEMENTS, AND LEASES:
1. Does the permit have any setback waivers, easements, or leases? ❑ Yes or �No
If yes, provide copies of all documents and complete the table below:
Document
Type
Grantor or
Parcel No.
Grantee
Expiration
Date
County
Registered
Deed
Book
Deed Page
Document
Description °
Select
Select
Select
Select
Select
Select
Select
a. The document description shall list any reduced setbacks with distance, etc.
2. For reclaimed water utilization permits:
Is reclaimed water utilized on property not controlled by the generator? ❑ Yes or [?(No
A lease, easement, or agreement must be provided allowing for the utilization of reclaimed water on the property or within the
facility. For irrigation of reclaimed water, an easement is required per 15A NCAC 02U .050](6). All documents shall be listed
in the table above.
FORM: NDSR 01-20 Page 3 of 4

State of North Carolina
�Department of Environmental Quality
Division of Water resources
NON -DISCHARGE SYSTEM RENEWAL
Division of Water Resources FORM: NDSR 01-20
VI. 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
2. Does the facility have an approved flow reduction [ 15A NCAC 02T .01 14(f)? ❑ Yes or [?(No
If yes, attach 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 value, the Permittee shall provide a reevaluation of
the reduced flow value using the methodology applied to the original flow reduction application. Also, attach a copy of the
flow reduction approval letter.
APPLI11C,,ANT'S CERTIFICATION 15A NCAC 02T .0106(b)
1, �l C �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 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. 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)
Signature: �"� Date: A
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 BRANCH
By U.S. Postal Service: By Courier: By Email:
Non -Discharge Branch Non -Discharge Branch — Archdale 942W [e-mail]
1617 Mail Service Center 512 N. Salisbury St.
Raleigh, NC 27699-1617 Raleigh, NC 27604
TELEPHONE NUMBER: [phone]
FORM: NDSR 0 1 -20 Page 4 of 4

State of North Carolina
Department of Environn►ent and Natural Resources
Division of Water Resources
! �n ,< ' 15A NCAC 02T .0000—SINGLE-I ANVV iiIrY RESIDENCE ASTGWA'i'F,R iRRiCAT10NSYSTEMS
� —n
nOPERATION AND MAINTENANCE AGREEMENT
Division of Water Resoue'ces FORM: SFRWWIS O&M 08-.13
Permit No. W Q 0 0 'j 4 2'L0
County: VJGLV-e
Property owner(s) as appearing on the recorded deed: TT?1 t ton 14-S5®L i;. � t L— Q
Mailing address: �- o - 3 6 )� A-L-55 -7 ��� t NC. Z'j S ® Z
Facility address: _ 1-�7,0 old US l HW4 Ne-w tAl1tl i4c
Irrigation Method: ❑ SPRAY [DRIP
I / We agree to operate and maintain the single-family residence wastewater treatment and irrigation system as follows:
1, The Pernittee is responsible for the operation and maintenance of the entire wastewater treatment and irrigation
system including, but not limited to, the following items:
a. The septic tank shall be checked annually and pumped out as needed.
b. The septic tank effluent filter shall be checked and cleaned annually.
c. Accessible sand filter surfaces shall be raked and leveled every six months and any vcgetative growth shall be
removed manually,
d. ❑ The tablet chlorinator shall he checked weekly. Wastewater grade tablets (calcium hypochlorite) shall be
added as needed to provide proper chlorination (pool chlorine tablets shall not be used), OR
❑ The ultraviolet disinfection unit shall be checked weekly. The lamp(s) and quatrtz sleeve(s) shall be
cleaned or replaced as needed to ensure proper disinfection.
e. All pump and alarm systems shall be inspected monthly.
f. The irrigation system shall be inspected monthly to ensure that the system is free of leaks, that all irrigation
equipment is operating as designed, that vegetative growth does not interfere with the system inspection or
operation, that the soil is assimilatingthe disposed treated wastewater with no visible runoff or ponding, and
that no objectionable odors are being generated.
2. Failure to pay the annual fee shall be cause for the Division to revoke the permit pursuant to 15A NCAC 02T
.0105(e)(3).
3. The Permittee's failure to properly operate this system is subject to a penalty up to $25,000 per day.
4. Failure to meet the permit conditions or violation of the State's surface water or groundwater regulations may void
the permit.
All owners appearing on the lef!ally recorded property deed shall sign this Operation & Maintenance Agreement
i / We understand the above requirements and agree to these terns as part of the issued permit.
Owner Signature; %10.f Date;
Owner Signature: _ Date;
FORM: SFRWWIS O&M 08-13 Page 1 of t

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Fairfield Subdivision
29R SFR i
PIN:0720560861
Real Estate I D: 0093556
Map Name: 0720 02
Owner: FAIRFIELD ASSOCIATES
Mailing Address 1: PO BOX 457
Mailing Address 2: APEX NC 27502-0457
Deed Book:002208
Deed Page: 00093
Deed Date: 01/01/1973
Deeded Acreage: 4.03
Assessed Building Value: $0
Assessed Land Value: $124,800
Total Assessed Value: $124,800
Billing Class: Business
Property Description: L029R MAP OF
CORRECTION FOR FAIRFIELD ASSOC
BM2008 -02236
Heated Area: 0
Site Address: 2820 OLD US 1 HWY
Township: Buckhorn
Year Built: 0
Total Sale Price: $0
Land Class: VACANT
Old Parcel Number: --
N
0 50 100 200 Feet
I I I I I I
1 inch = 100 feet
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