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Home My WebLink AboutWQ0018153_Application_20210809DW R Division of Water Resources State of North Carolina Department of Environmental Quality Division of Water Resources 15A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEM — RENEWAL FORM: SFRWWIS-R 02-21 Pursuant to 15,& N 0C 02IJIu l ei li 1 , if the application does not include all required information and the necessary supporting documentation, the application shall be returned. The application and attachments shall be prepared in accordance with 15,, , it ",fit .' ) i l X m 00 11;A NCA111)211'_0600, and Divislon m Policies. For more information, visit the Water Quality Permitting Section's Non -Discharge Branch v«rlusk . The Applicant shall submit an electronic copy of the application and attachments uploaded as a single Portable Document Format (PDF) file to lit He qw m m ou uilm m ml u�m lm� 7llw 'Ilh uuii.p hilt an1 ... lE21,ig ! YD , or emailed to ,Pgoiii lluisclka� c.'�1� ill �w� iu: ^urm w �, if less than 20 megabytes (MB). 1. Physical address: 6407 Carl Cox Rd. City: Bennett 1. Billing address: 6407 Carl Cox Rd. City: Bennett SECTION I — APPLICANT INFORMATION SECTION II - FACILITY INFORMATION County: Randolph State: NC SECTION III — BILLING INFORMATION 2. Verify the Applicant does not have any overdue annual fees: State: NC Zip: 27208- Zip: 27208- Pursuant to J51A.1 ! ,'AC _02II ` ,01 J 0f f.,, , permits for renewing facilities shall not be granted if the Applicant or any affiliation has an unpaid annual fee. FORM: SFRVMS-R 02-21 Pagel of 4 IV OPERATION AND MAINTENANCE AGREEMENT Permit No.: WQ0018153 Permittee: Paul and Sylvia Cox (i.e., all deeded property owners) County: Randolph The Permittee agrees to operate and maintain the single-family residence wastewater treatment and irrigation system as follows: 1. Inspect the septic tank annually, and pump out solids as needed. 2. Inspect and clean the septic tank effluent filter annually. (if applicable) 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. (if applicable) 4. Inspect the ultraviolet disinfection unit weekly. Clean or replace the lamps and quartz sleeves as needed. (if applicable) 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 leaks; that vegetative growth does not obstruct the spray heads; that the irrigated wastewater is not ponding in or running off the designated irrigation area; and that there are no objectionable odors. (if applicable) 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 (�halille 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 requirements and agree to these terms as part of the issued permit. Signature: �`° Date: _ Signature: .... �� ":m"' � ."� mo Date: Signature: Date: Signature:......_.. Date: All deededproperty owners shall sign this O eration and Maintenance A reement FORM: SFRWWIS-R 02-21 Page 2 of 4 ATTACHMENT A — SITE MAP .......... Was the facility originally permitted or had a major modification issued after September 1, 2006? F-1 Yes — Pursuant to 5,/A, l submit a site map pursuant to the requirements in P 5,,8, 1,,,CA' 0 B2' 'I These requirements are: ❑ 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. 0 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 �5./%,, CA(-' ('�,2 V J) � 0"17 andO 10,8, and 1 5,1\ 02 11 060 1 ❑ Setbacks as required by I SA 11"1(,,,"AQ 02 - 'I " ' ' 0f,"i06, ❑ 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. No — Skip Attachment A. ATTACHMENT B — SIGNATURE AUTHORITY DELEGATION Does the signature authority in Section 1, Item 3 meet the requirements pursuant to 1, 5,1�. 0 2"'J",0 I, 06(,-I)? Yes — Skip Attachment B. El No — Submit a letter pursuant to 15A 0 1 06�, authorizing the signature authority to sign. ATTACHMENT C — FLOW REDUCTION Does the existing permit include an approved flow reduction? ❑ Yes — Submit a copy of the flow reduction approval letter, as well as 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 flow reduction value, the Permittee shall provide a reevaluation of the reduced flow value pursuant to the requirements in Z NO — Skip Attachment C. ATTACHMENT D — EASEMENT, ENCROACHMENT, AND LEASE AGREEMENTS Does the Permittee own all of the land associated with the wastewater collection, treatment, conveyance, and irrigation system? E Yes — Skip Attachment D. ❑ No — Pursuant to 15.A 1",Q(-,A(,, 011 0 � 16�,c),, provide a copy of all easements, lease agreements, and encroachment agreements allowing the Permittee to operate and maintain the wastewater collection, treatment, conveyance, and irrigation system on property not owned by the Permittee. ATTACHMENT E — AFFILIATIONS Are the Permittee's affiliations of record correct? Yes — Skip Attachment E. ❑ No — Provide the corrected affiliations and their contact information. ATTACHMENT F — COMPLIANCE SCHEDULES Does the existing permit include any Compliance Schedules? (See Section I of the most recently issued permit) ❑ Yes — Submit documentation that the compliance schedules have been met. [] No — Skip Attachment F. FORM: SFRWWIS-R 02-21 Page 3 of 4 ATTACHMENT G — CIVIL PENALTIES AND OUTSTANDING VIOLATIONS Does the Permittee have any existing civil penalties or outstanding violations? ❑ Yes (civil penalties) — Submit payment for the civil penalty, or proof of remission request. ❑ Yes (violations) — Submit a copy of your response to the Notice of Violation. ® No — Skip Attachment G. ATTACHMENT H— SETBACK WAIVERS Does the existing permit include setback waivers? ❑ Yes — Pursuant to 15 ,T1 .i I O,y,ll„„,0,16 ((4 ,�,, provide setbacks waivers that have been written, notarized, signed by all parties involved, and recorded with the county Register of Deeds. Waivers involving the compliance boundary shall be in accordance with 1." A 1 ^X AC 0' 1... 0 107w ® No — Skip Attachment H. APPLICANT'S CERTIFICATION I, that this application (Signature authority's name as noted in Section I, Item 3) 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 15 A NCA,C 02T.01 2 0j, , ';, 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 NQ 1, 111T .01116(4). An alternate person may be delegated as the signing official if a letter is provided pursuant to 15A NCAC 0 T 0106.. �Pursuant to § 1432 p5,,6A, and § .11 3,: V .fi% 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: A? ' 614m��.� .... Date: Co THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA: Email: Laserfiche Upload: Wm::�ui, :� IIII :� �:muutlr��:�:� Diem �w�aa�1ly nm�71h- _. .k 1 _ Stfllll:�n:ldal Form V ui 2 FORM: SFRWWIS-R 02-21 Page 4 of 4