WQ0006493_Application_20221104

DWR
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources
15A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE
WASTEWATER IRRIGATION SYSTEM — RENEWAL
FORM: SFRWWIS-R 02-21
Pursuant to 15A NCAC 02T .0107, 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 15A
NCAC 02T .0100, 15A NCAC 02T .0600, and Division Policies. For more information, visit the Water Quality Permitting
Section's Non -Discharge Branch website. The Applicant shall submit an electronic copy of the application and attachments
uploaded as a single Portable Document Format (PDF) file to littps://edoes.deg.nc.jzov/Forms/NoriDiscliar e-Branch-Subinittal-
Form-Ver2, or emailed to Non-Disehar e.Re orts a ncdenr, ov if less than 20 megabytes (MB).
SECTION I — APPLICANT INIi ORMATION ....
1.
Applicant: James K & Tracy W Hall
2.
Permit No.: WQ006493
3.
Signature authority: J. Keith Hall
Title: Owner
4.
Mailing address: 5781 Union Ridge Rd
City: Burlington
State: NC Zip: 27217-
5.
Contact person: Keith Hall
Primary phone number: [phone] Select
Email: [e-mail]
Secondary phone number: [phone] Select
6.
Secondary Contact person: Tracy Hall
Primary phone number: [phone] Select
Email:
Secondary phone number: ( ) - Select
SECTION II FACILITY INFORMATION
1. Physical address: 5781 Union Ridge Rd County: Alamance
City: Burlington State: NC Zip: 27217-
SECTION III BILLING INFORMATION
1, Billing address: 5781 Union Ridge Rd
City: Burlington State: NC Zip: 27217-
2. Verify the Applicant does not have any overdue annual fees:
littps:Hdeq nc.ov/about/divisions/water-resources/water-resources-permits/wq-epayrncuts
Pursuant to 15A NCAC 02T .0120(c), permits for renewing facilities shall not be granted if the Applicant or any affiliation has
an unpaid annual fee.
FORM: SFRW WIS-R 02-21 Page 1 of 4

SECTION EV OPERATION AND MAINTENANCE; AGREEMENT
Permit No.: WQ006493 County: Alatnance
Permittee: James K & Tracy W Hall (i.e., all deeded property owners)
The Perm ittee agrees to operate and maintain the single-farn i ly 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 Change of Ownershi a plication 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:
Signature:
Signature:
Signature:
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LD
Date: { -r ' Z-
Date:
Date:
Date:
All deeded proper(y. owners shall sign this Operation and Maintenance Agreement
FORM: SFRW W IS-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?
❑ Yes — Pursuant to 15A NCAC 02T .0I 05(d), submit a site map pursuant to the requirements in 15A NCAC 02T .0604(d). 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.
❑ 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 15A NCAC 02L .0107 and .0108, and 15A NCAC 02T .0601.
❑ Setbacks as required by 15A NCAC 02T .0606.
❑ 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 15A NCAC 02T .0106 b ?
® Yes — Skip Attachment B.
No — Submit a delegation letter pursuant to 15A NCAC 02T .0106(c),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 15A
NCAC 02T .0114(f).
® 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?
® Yes — Skip Attachment D.
❑ No -- Pursuant to 15A NCAC 02T .01.16 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? Check affiliations.
® 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

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 15A NCAC 02T .0606 c , 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 15A NCAC 02L ,0107.
❑ No — Skip Attachment H.
APPLICANT'S :CERTIFICATION
I [ attest that this application
(Signature authority's name as noted in Section 1, 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 15A NCAC 02T .0120 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 .0106(b). An alternate person may be delegated as
the signing official if a letter is provided pursuant to 15A NCAC 02T .0106 c . Pursuant to § 143-215.6A and § 143-215.6.8, 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:
Date:
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF PILE VIA:
Email:
Non-Discharite.Reports a.ncdenr. ov
Laserl:che Upload:
htt[3s://edoes.deg.nc,gov/Form s/NonDisch a rge-Bra n ch-
Submittal -Form -Vert
FORM: SFRWWIS-R 02-21 Page 4 of

oraared, and re',.rn o Gr<:dy Jcserh `1�it88!ar.
F.
L�, ;_,. 371, 0mlrtmi, e C 27253
NORTH CAROLINA
ALAMANCE COUNTY
EASEMENT
This EASEMENT, conveyed the day and year hereinbelow written,
by Kenneth David Rudd and wife, Rabin S. Rudd, hereinafter referred
to as Grantors, to James Keith Mall and wife, Tracy Wynn Hall,
hereinafter referred to as Grantees;.,
W I T N E S S E T H
WHEREAS, the Grantors are owners of certain real property
shown as Lot One of the Easement plat for Keith Ball and Kenneth
Rudd, recorded in the office of the Register of Deeds for Alamance
County in Plat Book 46 at page 85 , as well as in Plat Dook 32
at page 191, which said plats are incorporated as a part of this
Easement by reference; and
WHEREAS, the Grantees are owners of certain real property
shown on said plats referred to hereinabove as Lot Two; and
WHEREAS, in order to install, maintain, and operate a waste
disposal system which has been designed for property of said
Grantees, it is necessary that an easement be granted over property
of the Grantors to allow the specially designed system to function
properly;
NOW, THEREFORE, for good and valuable consideration, including
a reciprocal easement, the receipt of which is hereby acknowledged,
the Grantors hereby grant, bargain, and convey to the Grantees the
following easement:
1. Grant of Easement. The Grantors do hereby grant a per-
petual easement over the land described hereinbelow to the Grantees
for the purpose of providing a spray field for the operation of
a waste disposal system especially designed for the adjoining
property, which is owed by the Grantees. The Grantees shall have
the right to use the land described hereinbelow for the installa-
tion, operation, and maintenance of the waste disposal system for
a single family dwelling which is or will be located on the prop-
erty of the Grantees.
2. Description of Area of Easement. The real property of the
Grantors over which the easement is granted is described as
follows:
That certain tract or parcel of land located in
Faucette Township, Alamance county, North Carolina,
being a portion of Lot 1 of the Easement Plat for Keith
Ball and Kenneth Rudd referenced hereinbelow, and more
particularly described as follows:
BEGINNING at a point in the common property line of the
parties, said point being South 55° 52' 12" East 72.63
feet from a point in the center of S.R. 1001 at the
intersection of the northwestern corner of Lot 1
(property of Kenneth Rudd) and the northernmost corner
of Lot 2 (property of Keith Hall), and going the
following courses and distances: Along a curve to the
right with a radius of 184.0 feet a length of 292.71
feet to a point in the common property line of the
parties; thence North 550 52' 12" West 262.80 feet to
the point of BEGINNING, and BEING 0.23 acres, more or
less, said area being shown on a plat entitled Easement
Plat for Keith Hall and Kenneth Rudd dated .April 28,
1992 by Simmons Engineering & Surveying, File 920301BE,
and recorded in the office of the Register of Deeds for
Alamance County in Plat Book 46 at page 85 , which
said plat is incorporated herein by reference.

3. Duration of Easement. Said easement is perpetual and
shall be binding on the Grantors, their heirs, or successors in
title, and shall innure to the benefit of the Grantees, their heirs
and successors in title.
IN WITNESS WHEREOF, the Grantors have set their hands and
seals this w, day of July, 1992.
¢ 0_ LIA'U@1-
(SEAL)
Venneth David Rudd
(SEAL)
Rya n S . Rudd
NORTH CAROLINA
ALAnANCE COUNTY
I, r:Ef„,7,.: ' , yr .,,7- - , a Notary Public of said County
and State, do hereby certify that Kenneth David Rudd and Robin S.
Rudd personally appeared before me this day and acknowledged the
due execution of the foregoing instrument.
Witness my hand and official. seal this ,Z/ day of July,
1992.
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