WQ0006021_Application_20210830

State of North Carolina
DWRDepartment of Environmental Quality mvision of Water Resources
Dlvk1on of Water litesovices 15A NCAC 021'.0600 — SINGLE-FAMILV RESIDENCE
WASTEWA"rER IRRIGATION SYSTEM —C14ANGE OF ()WNLRSFIIP
FORM: SFRWWI'S-CO t13-21
Pursuant to 15A INCAC 0211 �W0701)�, if the application does not include all required information at)(] the necessary
supporting documentation, the application shall be returned. The application and attacliments shall be prepared in
accordance with 15.A NCAC,021 gioo, 15A NCAC 021" .0000, and Division Poh—CLin. For more information, +a,jsit the Water
Quality permitting Section's Non -Discharge Branch vvebs " i " t ' v, The Applicant shall submit an electronic copy of the aPPlicstiOn
and attachments uploaded am
s a single Portable Docuent Format (PDF)file to
or ernailed to Non-ffi��Ul at _ac�jLqg g
if less than, 20 ine.abytes (M
I . Physical address: fa 3 9 LA C fk 4 "rl 6 12- 0 04 Fa K'm
1 Billing address: Wt,9'111& M P I_V7n
City: r, AA m I f-I �
County: C+\C
aVYN
State: N C zip:
State: zip: 2,71 1
Has a deed been executed' and recorded in the County Register of Deeds pursuant to 1CAC 02T_,Q ._f J�D?
gyes _ Complete items I through 4 b0ow.
E] No ­ See Attachment B on ["age 3,
I . Parcel No.:
3, Deed Book:
2. Date of Purchase:
4, Deed Page Nos.:
FORM: SFRWWTI S-CO 03-21 Page I of 3

Permit No.: WQOO
Permittee: (i.e., all deeded property owners)
County:
The Permittee agrees to operate and maintain the single-Ennifly residence wastewater treatment and irrigation system
,as follows:
1. Inspect tile septic tatik annually, and putrip out solids as needed.
2. Inspect and clean the septic tank effluent filter annually. Ql'al.yVicuble)
3. Inspect the tablet chlorinator weekly, Add wastewater grade chlorine tablets (e.g., calcium hypocillorite) as
needed. Swimming pool grade chlorine tablets are riot acceptable. Ql'aly),ficable) nC*, GLA, � t) �,,-e
re (k 11 -el
4"h e S e s Ol
4. Inspect the ultraviolet disinfection unit weekly, Clean or replace the latups and nartz sleeves as needed. QJ
oplVicable)
5. Inspect all storage tanks, pumps,, and alarms monthly. Remove the floating scum layer in all purnp/storage tanks
when pumping, the septic tank, solids out. I/
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; (fiat tile irrigated wastewater is not ponding in or
running offthe designated irrigation area; and that there are no objectionable odors. (if applicable) v'l
7. Inspect the drip irrigation system monthly to vcrifyY: proper operation of the drip lines; that there are no leaks; that
vegetative growth does not obstruct the drip emitters; that (lie irrigated wastewater is not ponding in, or running
off the designated irrigation area; and that there are no obJectionable odors, (rf applicable)
8. Maintain a set of Division -approved engineering plans and specifications.
9. Pay the required annual fee.
10, Request renewal of this pert -nit on Division -approved forms no later than 180 days prior to expiration,
I L Sign and provide a C h sof Ov, r e " h ili atioil to any future owner of the single-family residence
wastewater treatment and irrigation systern for their completion and submission to the Division of Water
Resources.
UWe understand the above requirements and agree to these terms as part of tile issued permit.
Signature:
L Date: 4ti�b �Vlr
,Signature: 2 ;!x
Date -
Signature: Date:
Signature: Date:
All deeded' properly owners shall sign this Operation and Maintenance Aereement
SFRWWIS-CO 03-21 Page 2 of 3,

A17ACITMEA,T A ­ $J
Does the signature authority in Section 1, Item': meet tile requirernents pursuant lo I "S'A N(IN(" 02 (_,,C)[06
Yes ­ Skip Attachment A, C11 IrC
El No Submit a (OqJvgn�Jo wp M r pursuant to N 5A �,4('A(' 02 011 00(C) authorizing the signature authm-ity to si V!,
ATTACHMENT B—PROPERTV
Has a deed been executed and recorded in the County Register of'Deeds pursuant to )JA NCAC'021' 06,).4 ()()?
�es ­ COMPICIC Items I through 4 in Section IV on page I
L1 No
0 Submit a written notarized intent to purchase agreement sign by both parties with a plat or survey map pursuant to 115A
NC,A__C 02'r 106(i, !(gjQ -or
.1 _. _.., DI
El Submit a written notarized lease agreernent that specifically indicates the intended use of the property and has been signed
by both parties, as well as a plat or survey map pursuant to 15 A NCAC 021',,0604,(a,)(,j), Lease agreements shall adhere to
the requirements ofII
L T
an J d R attest that this
(Signature authority's name as noted in Section 1, Item 3)
has been revievved by me and is accurate and complete to the best of my knowIedge. I understand that if all required parts of this
application package are not completed, and that if' all required supporting information, and attachrilents are not included, this
application package will be returned as incornpliete. I further certify pursuant to 15A NCA( 1, _02 'r '_O 201 b),, that the applicant, or
any parent, subsidiary, or other affiliate of the applicant has: not been convicted of" environniental crimes under; not previously
abandoned a wastewater treatment facility without properly closing the facility; not paid a civil penafty; not been compliant with
any compliance schedule in a permit, settlement agreement, or, order; not paid an annual fee.
Note: "r'he Applicant's Certification shall be signed pursuant to 15A NCAC, Q2L,O w016 b . An alternate person may be delegated
as the signing official if a letter is, provided pursuant to 15A ' NC A,( ' 0 " 2' " I " ',,0 " 016 " (g). Pursuant to § and
any person who, knowingly roakes any false statement, representation, or certification in any application package shall, be guilty ofa
Cfa5s 2 iriisderneallnor, which may include a fine not to exceed $ 10,000 as wejtAs-civil penalties up to $25,000 per violation.
nr
9)
Date:
Signature,:
TI,IE COMPLETED APPLICATION AND ATTAC14MENTS SHALL BE SUBMITTED AS A SINGLE PD,F FILE VIA:
E MLILI: Laserficbe Upload:
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F01M S17RWWI'-;,CO 03�21
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