WQ0024301_Application_20231002

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 .01 07(h), 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 .01011, 15A NCAC 02T .0600, and Division Policies. For more information, visit the Water Quality Permitting
Section's Non -Discharge Branch w-ebsite. The Applicant shall submit an electronic copy of the application and attachments
uploaded as a single Portable Document Format (PDF) file to htt ps://edocs.de .nc.uov/Forms/NonDischarue-Branch-Suhmittal-
Form-Vert, or emailed to Non-Dischar e.Re orts(dLncdenr..-ov if less than 20 megabytes (MB).
SECTION I — APPLICANT INFORMATION
1.
Applicant: Thomas J. Gilbert Jr.
2.
Permit No.: WQ0024301
3.
Signature authority: Thomas J. Gilbert Jr.
Title: Owner
4.
Mailing address. 11500 Lakeview Lane W
City: Minnetonka
State: MN Zip: 55305-
5.
Contact person: Thomas Gilbert
Primary phone number: (612) 741-275 Cell
Email: [e-mail]
Secondary phone number: ( ) - Select
6.
Secondary Contact person: Valerie Gilbert
Primary phone number: [phone] Cell
Email: [e-mail]
Secondary phone number: ( ) - Select
SECTION 11— FACILITY INFORMATION
�1. Physical address: 152 Hickory FIats Rd County: Caswell
City: Leasburg
State: NC
Zip: 27291-
SECTION III -- BILLING INFORMATION I
L Billing address: 11500 Lakeview Lane W
City: Minnetonka State: MN Zip: 55305-
2. Verify the Applicant does not have any overdue annual fees:
https_ll ftgq nc.gov/about/divisions/water-resot rce5lwater-resources-permits'wa-ena�ment5
Pursuant to 15A NCAC 02T .0120(cl permits for renewing facilities shall not be granted if the Applicant or any affiliation has
an unpaid annual fee.
FORM: SFRWWIS-R 02-21 Pagel of4

SECTION IV — OPERATION AND MAINTENANCE AGREEMENT i
Permit No.: WQ0024301 County: Caswell
Permittee: Thomas J. Gilbert Jr. and Valerie Gilbert (i.e., all deeded property owners)
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 hypoeblorite) 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 acid 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 Ownership application to any future owner of the single-family residence wastewater
treatment and irrigation system for their completion and submission to the Division ofWater Resources.
I/We understand the above requirein7agree to these terms as part of the issued permit.
Signature: t• Date: a
Signature: Date: `''Ll
Signature: Date:
Signature: Date:
All deeded property owners shall sign this Operation and Maintenance Agreement
FORM: SFRVIMS-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 .0105(d), submit a site map pursuant to the requirements in 1_5A NCAC 02T .0%4-These
requirements are:
❑ A scaled map of the site with topographic contour intervals not exceeding 10 feet or 25 percent oftotal 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 021. _0107 and .0108, and 15A NCAC 02'r .0601,
❑ Setbacks as required by 15.1\ NCAC _Q22T-.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.
I ATTACHMENT B — SIGNATURE AUTHORITY DELEGATION
Does the signature authority in Section 1, Item 3 meet the requirements pursuant to 1_5A NCAC 02T .01116(b f?
® Yes — Skip Attachment B.
❑ No — Submit a d le gation letter pursuant to 15A NCAC 02T .01 06c authorizing the signature authority to sign.
ATTACHMENT C — FLOW REDUCTION I
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 15 A
® 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 112T .0 11 h(c 1, 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_
f ATTACHMENT H — SETBACK WAIVERS I
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 1 � A NCAC 021, 010'7,
® No -- Skip Attachment H.
APPLICANT'S CERTIFICATION
I, m (ks 'T C-11he-ec it 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 _N_CAC 02T .01.20fh�, that the applicant, or any
parent, subsidiary, or other affiliate ofthe 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 15_6A and § 143-215.6B, any
person who knowingly makes lse statement, representation, or certification in any application package shall be guilty of a Class
2 misdemeanor, which may i yd`e a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature:
Date. g--�:42 - � 3
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email:
Non-Discha rge.Reports(& ncdenr. gov
Laserfiche Upload:
https_: //ed ncs.deg. nc.uo`•/Fo r_m s/Non Discha rge-Branch-
Submittal-Form-Ver2
FORM: SFRWWIS-R 02-21 Page 4 of