WQ0009280_Application_20221219

DWR
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 15A NCAC 02T .0107(b), 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 hays://edocs.deo.nc.gov/Forms/NonDischarce-
Branch-Submittal-Form-Ver2, or emailed to Non-Dischar�e.Reportsru ncdenr.t ov Vless than 20 megabytes (MB).
{ .SECTION I — APPLICANT INFORMATION f
11. Applicant: Elwood M. and Tammy N. Dodson j
i 2. Permit No.: W00 9290 I
j 3. Signature authority: Elwood M_ Dodson Title: Owner J
4. Mailing address: 2453 Kerrs Chapel Rd.
t
City: Burlington State: NC Zip: 27217-
5. Contact person: Elwood M. Dodson Email: [e-mail]
Primary phone number. [phone] Home Secondary phone number:
6. Secondary Contact person: Tammy N. Dodson Email:
Primary phone number: [phone] Home Secondary phone number: ( ) - Select J
! SECTION H — FACILITY INFORMATION I
1. Physical address: 2453 Kerrs Chapel Rd. County: Caswell
J City: Burlington State: NC Zip: 27217-
j SECTION III — BILLING INFORMATION f
1. Billing address: 2453 Kerrs Chapel Rd.
I Citty: Brlrhnown State: NC Zip: 27217-
2. Verify the Applicant does not have any overdue annual fees:
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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. J
FORM: SFRWWIS-R 02-21 Page 1 of 4

SECTION IV — OPERATION AND MAINTENANCE AGREEMENT
County: Caswell
Permit No.: W0009230 t3'
1 Permittee: Elwood M. and Tammy N. Dodson (i.e., all deeded property ownors)
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
appficable)
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 .nee of Ownership application to any future owner of the single-family residence i
wastewater treatment and irrigation system for their completion and submission to the Division of Water
kesour=s.
I/We understand the above requirements and agree to these terms as part of the issued hermit.
Signature: 1 ` Date:
i
I Signature: Date: l — 6G
`. Signature: Date:
Signature: Date:
All deemed Vroperty owners shall sign this Operation and Maintenance Agreement
FORM: SFRW WIS-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 .0105r e , submit a site map pursuant to the requirements in ,,A NCAC 02T .0604i dr.
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. I
1 [ 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. ]
1 Q["No — Skip Attachment A.
{ ATTACHMENT B — SIGNATURE AUTHORITY DELEGATION 1
Does the signature authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106i b 0 ❑
Q[-es — Skip Attachment B.
❑ No— Submit a c..,.., —Jn ieuer 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 j
requirements in. 15A NCAC 02T .0114(t)-
❑`— Skip Attachment C. _ 1
ATTACIEWENT D — EASEMENT. ENCROACHMENT. AND LEASE AGREEMENTS
Does the Permittee own all of the land associated with the wastewater collection, treatment, conveyance, and irrigation system?
❑�s — Skip Attachment D.
❑❑ No — Pursuant to 15A ELT .01161 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
Arethermittee's affiliations of record correct? Check affiliations.
❑ Yes — Skip Attachment E.
] ❑Q 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)
i Q Yes — Submit documentation that the compliance schedules have been met.
❑E3-No — Skip Attachment F.
FORM: SFRWWIS-R 02-21 Page 3 of Y

j ATTACIil1EM G— CIVIL PENALTIES AND OUTSTANDING VIOLATIONS !
Does the Permittee have any existing civil penalties or outstanding violations?
LLJ Yes (civil penalties) — Submit payment for the civil penalty. or proof of remission request.
LJLI Yes,(violations) — Submit a copy of your response to the Notice of Violation.
j 1vo — Skip Attachment G.
ATTACHMENT H — SETBACK WAIVERS
Does the existing permit include setback waivers?
OO Yes — Pursuant to 15A NCAC 02T .0606[ c 1, provide setbacks waivers that have been written, notarized, signed by all parties I
# involved, and recorded with the county Register of Deeds. Waivers involving the compliance boundary shall be in accordance
! with 15A NCAC 02L .0107_
Flg-No — Skip Attachment H.
APPLICANT'S CERTIFICATION
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 s, 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.
Nate: The Applicant's Certification shall be signed pursuant to 15A NCAC 02T .01061 b 1. 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 § 143-215.6B,
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 Opt to exceed $10,000 as well as civil penalties up to $25,000 per violation.
I Signature:
Gate: IL--1� ` f
_ UMIPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email:
Non-Discharae.Reportsra ncdenr.pov
Laserfiche Upload:
hl tps:Hedocs.deg.nc.,zov/Forms/NonDischarge-Branch-
Submittal-Form-Vert
FORM: SFRWWIS-R 02-21 Page 4 of -i