WQ0016400_Application_20210414

DWR
State of North Carolina
Department of Environmental Quality
Division of Water Resources Division of Water Resources
I5A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE
WASTEWATER IRRIGATION SYSTEM — CHANGE OF OWNERSHIP
FORM: SFRWWTc_rn no2 -,.
Pursuant to 15A NCAC 02T .0107 b , if the application does not include all required information and the necessarysupporting
documentation, the application shall be returned. The application and attachments shall be prepared in accordance with 15
(NCAC 021 .0100, 15A NCAC 02T .0600, and Division Policies. For more information, visit the Water pporting
Section's Non -Discharge Branch website. The Applicant shall submit an electronic copy of the application and attachments
Quality Permitting
uploaded as a single Portable Document Format (PDF) file to htt s://edocs.de .nc. ov/Forms/NonDischar e-Branch-Sachmeal-
For, zn-Ver2, or emailed to Non- Dischar e.Re orts ncdenr. ov if less than 20 megabytes
(MID).
SECTION I —APPLICANT INFORMATION
1. Applicant: Mark W. Kemp and Hope Newman Kemp
2. Permit No.: WQ0016400
3. Signature authority: /
4. Mailing address:
City: ZR" r11, ►� fJ•� /''C. D� �.2 I
5. Contact person:
Primary phone number: (�]�l /$ Iect
6. Secondary Contact person: [�G
Primary phone number:�3(o)' YV AS24lect
Title:
�— ffar
State: Zip: '2—
Email: km A
Secondary phone number: ( ) - SeIect
Email:
Secondary phone number: ( ) - Select
SECTION II — FACILITY INFORMATION
L Physical address: Parcel No.8970748546 Joyful Way Lane County: AIamance
City: Burlington
State: NC
SECTION III — BILLING INFORMATION
I. Billing address: 3"`f :� vU�•' Sc> — i f
City: lJi S r/) "1 s A, t ., State: /V&_
SECTION IV — DEED INFORMATION
Zip: 27217-
Zip:
Has a deed been executed and recorded in the County Register of Deeds pursuant to 15A NCAC 02T .0604(e)f 1)?
® Yes — Complete Items I through 4 below.
❑ No — See Attachment B on Page 3.
L Parcel No.: 8970748546
3. Deed Book: 3759
2. Date of Purchase: 01/31/2018
4. Deed Page Nos.: 0255 - 0259
FORM: SFRWWIS-CO 03-21 Pagel of 3

SECTION V — OPERATION AND MAINTENANCE AGREEMENT
Permit No.: WQ0016400
County: Alamance
Permittee: Mark W. Kemp and Hope Newman Kemp (i.e., all deeded property owners)
The Permittee agrees to Operate and maintain the single-family residence wastewater treatment d
follows: anirrigation system as
y
Inspect the septic tank annually, and pump out solids as needed.
Inspect and clean the septic tank effluent filter annually. (ifapplicable)
3. Inspect the tablet chlorinator weekly. Add wastewater grade chlorine tablets (e.g., calcium hypochlorite) as needed.
Swimming pool grade chlorine tablets are not acceptable. (fapplicable)
4. Inspect the ultraviolet disinfection unit as needed. weekly. Clean or replace the lamps and quartz sleeves i
applicable) (f
5. Inspect all storage tanks, pumps, and alarms monthly. Remove the floating scum layer in all pump/storage tanks
when pumping the septic tank solids out.
6. Inspect the spray irrigation system monthly to verify: proper operation of the spray heads,
that there are no leak
that vegetative growth does not obstruct the spray heads; that the irrigated wastewater is not p nding in or running
off the designated irrigation area; and that there are no objectionable odors. (ifapplicahle)
7. Inspect the drip irrigation system monthly to verify: proper operation of the drip lines; that there are no leaks; that
vegetative growth does not obstruct the drip emitters; that the irrigated wastewater is not ponding in or running off
the designated irrigation area; and that there are no objectionable odors. (if applicable)
8. Maintain a set of Division -approved engineering plans and specifications.
9. Pay the required annual fee.
10. Request renewal of this permit on Division -approved forms no later than 180 days prior to expiration.
11. Sign and provide a Change of Ownershi a lication to any future owner of the single-family residence wastewater
treatment and irrigation system for their completion and submission to the Division of Water Resources.
I/We understand the above requireme is and agree to these terms as part of the issued permit.
Signature: Date:
Signature;
Date:
Signature:
Signature:
Date:
Date:
All deeded property owners shall sign this Operation and Maintenance A regiment
FORM: SFRWWIS-CO 03-21 Page 2 of

ATTACHMENT A — SIGNATURE AUTHORITY DELEGATION
Does the signature authority in Section 1, Item 3 meet the requirements pursuant to 15A NCAC 02T 0106(bl?
® Yes — Skip Attachment A.
❑ No — Submit a delegation Ietter pursuant to I SA NCAC 02T .0106 c authorizing the signature authority to sign.
ATTACHMENT B — PROPERTY OWNERSHIP DOCUMENTATION
r1HIased been executed and recorded in the County Register of Deeds pursuant to— Complete Items 1 through 4 in Section IV on Page 1.
❑ Submit a written notarized intent to purchase agreement sign by both parties with a plat or survey map pursuant to L5A NCAC
02T .0604(eN2); or
both parties, as well as a plat or survey map pursuant to
❑ Submit a written notarized lease agreement that specifically indicates the intended use of the property
ISA NCAC 02T .0604 e 3 . menu shall adherhas bee e to the
edby
requirements of 15A NCAC 02L .0107. Lease agreements
APPLICANT'S CERTIFICATION
(Si a e authority's name as noted in Section 1, Item 3) 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 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 pursuant to 15A NCAC 02T .012Q b , that the applicant, or any
parent, subsidiary, or other affiliate of the applicant has. not been convicted of environmental crimes under; not previously abandoned
a wastewater treatment facility without properly closing the facility; not paid a civil penalty; not been compliant with any compliance
schedule in a permit, settlement agreement, or order; not paid an annual fee.
Note: The Applicant's Certification shall be signed pursuant to 15A NCAC 02T .0l Qb{b), An alternate person may be delegated as
the signing official if a letter is provided pursuant to 15A NCAC 0210106(cl. Pursuant to § 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, whit ay include a fine not toexceed$10,000 as well as civil penalties up to $25,000_ per violation.
Signature:
Date:
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA -
Emig:
Non-Dischar e.Re Ports( nedenr. v
Laserfiche Upload:
htt s://edoes.de .nc. ov/Forms/NonDisehar e-Branch-
Submittal-Form-Vert
FORM: SFRWWIS-CO 03-21
Page 3 of 3