WQ0029555_Application_20230424

State of North Caro
ling
Department of Environmental Quali"
Division of Water Resources
INNrIsSon of Water Resources 15A NCAC 02T .0600 - SINGLE-FAMILY RESIDENCE
WASTEWATER IRRIGATION SYSTEM - CHANGE OF OWXERSUf IP
FORM: SFRWWIS-CO 03,m2l
Pursuant to IAA NCAC 02T .0107(b), if the application does not include all r
documentation., the application shall be returned. The application and a
NCAC 02T .Ulllll, IrAA NCAC 02T .0600, and Division Policies. For more i
Section's ion -Discharge Branch website. The Applicant shall submit
uploaded as a single Portable Document Format (PDF) File to https:Ucd(
Form -Vert, or emailed to N.on-Discharj2je. Repo rtsnncden r.j!ov if less t
equi
ttachmen
I Applicant: John and Lisa Durizch
?. Permit No.: WQO00) q5>5
�d information and
ts shall be prepare
the necessary supporting
achments
s.dea.nc.�o� /Forms/Nonl)ischaree-Branch-Subniittot,..
han 20 megabytes (MB).
n accordance with I �A
nformatis'on, visit the Water Quality Permitting
an electronic copy of the application and att
3. Signature authorltV: Lisa Durizch Title: Owner
4. Mailing address: 62.7 Willie Pace Road
Cl'q.*: Burlington State: NC Z'10D: 27217-
.5. Contact person: Lis
Prioman�
00
a Durizch
phone number. {.j�qy,�-�_ select
6. Secondar"s-r
v
t person: John Durizch
Primar., phone number. (cl t4i 9Ilse lect
Contac
I. Physical address: 627 Willi
C ItN a Burlington
City: X r I %^A A,"
e Pace Road
Has a deed been executed and recorded in the
I
Yes — Complete Items 1 throuv.,h 4 below.
❑ No —See Attachment B on Page 3.
I. Parcel No.,.- 8990.0.). 1
3. Deed Book: 4311
FORM: SUR
03,,11
:ILI
Email: Ifir le"c ychoo
Secondary phone number:
Select
Emai I: r i 2 4-l+ � `� a ►1�_ [fir►
Secondary phone number: ( ) - Select
County: Alamance
State.* N C
State:
W
ounty Register of Deeds pursuant to 15
Zip: ?7217-
ZIP: 7411
C T 0604
�. Hate of Purchase: March 31, 1011 �
4. Deed Page Nos... 0045 - --1
i�
-
r,
a�

ROY COOPER
co"Wnff
1ZARVTt�i c orc.-+
County: Alamance
Permit No.: WQ0019555 I
Permittee: John and Lisa Durizcli (i.c., all deeded property owners)
The Pe ittee agrees to operate and maintain the single-family residence wastewater treatment and irrigation system as
follows: �
i I. Inspect the septic tank annually, end rump out solids as needed.
I
2. Inspect and clean the septic tank effluent filter annually. (inapplicable)
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 spra}� irrigation system monthly to verify: proper operation of the spray heads-, that there are no leaks;
that vegetative gro\N-th does not obstrLICt the spray heads', that the irrigated wastewater is no[ 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 verir� : proper operation of the drip lines.: that there are no leakfs; 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. (i/�upplicable) i
8. Maintain a set of Division -approved engineering plans and specitications.
9. Pay the required annual fee.
I0. Request renewal of this permit on Div Ision-appro\:-'ed 1'orms no dater than 180 days prior to exp*rat*on.
I I . Sign and provide a ChanV1e of Ownership application 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.
1/We understand the above requirements and agree to these terms as part of the issued permit.
� Signature: � ���^ �� Date: � / Z-�'/ Z3
Signature: Date:
I
Signature: _ Date:
S i gnat u re: -- Date:
All deeded properiN- oN% per. shall sien this Operation and Maintenance Aaree ment
FORM: SFRWWIS,,CO 03m2i Page 2 of
3

Does the signature authority in Section I.. Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)?
Yes - Slip Attachment A.
E:1 No - Submit a delegation letter pursuant to I 5A NCAC 02 T
0106(c) authorizing the signature authority to sign.
Has a deed been executed and recorded in the County Register of Deeds pursuant to.1 SA NCAC 02.T 0604
Z Yes - Complete Items I through 4 in Section IV on Page IS
❑ No
I )?
El Submit a written notarized intent to purchase agreement sign by both parties with a plat or survey map pursuant to I �A NCAC
0_2T -0604(�.)(4,,._)l- or
❑ Submit awritten notarized lease agreement that speciticalkindicates the intended use of the property and has been signed by
both parties, as well as a plat or survey map pursuant to IAA NCAC 0.21T .0604(e)(3). Lease agreements shall adhere to the
requirements of I 5A NC..,%C 02 L .0107.
attest 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 ipartsoff all required 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 01-F .0110(b), that the applicant,, or any
parent, subsidiary, or other affiliate of the applicant has: not been convicted of environmental crones 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 per -lit, settlement agreement, or order;not paid an annual fee.
Note-, The Applicant's Cert ification shall be signed pursuant to I SA NCAC OAT .01061b). An alternate person matt be delegated as
the signing official if a letter is provided pursuant to I �A NC,,\C OAT .0106(c). Pursuant to § 144- A) 15.6A and ; I4 I .613, anv
person who knowingly makes any false statement, representation, or certification in anv application package shall be ;uilri of
misdemeanor, which may include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
/I
Signature-.
u QV
U
Date: �/
a Class
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email0
:
Non,,Dischjroe.Re ortsfa nedenr.
FORM. SI R %k W I S -C03-mi1
01%,
Laserfiche Upload:
hrt�s://edocs.cleu.nc.eov/Forms/NonDi.charc.,Pt•-1irmach-
Subm ittio I- Form- Ver.' .0