WQ0039827_Application_20240304

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 ISA NCAC 02T .0107b , 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 https•//edoes.dep.ac.govlFormslNonDischarge-
Branch-Submittal-Form-Ver2, or emailed to Non-Discharge.Reports(ancdenr.gov if less than 20 megabytes (MB).
SECTION I — APPLICANT INFORMATION
1. Applicant: Martin S. Thompson and Rebecca J. Thompson
2. Permit No.: WQ0039827
3. Signature authority: Martin S. Thompson and Rebecca J. Title: Owners
Thompson
4. Mailing address: 3700 Thompson Woods Ln.
City: Oxford State: NC Zip: 27565-
5. Contact person: Martin S. Thompson Email: [e-mail]
Primary phone number: [phone] Home Secondary phone number: ( ) - Select
6. Secondary Contact person: Rebecca J. Thompson Email:
Primary phone number: [phone] Home Secondary phone number: ( ) - Select
SECTION II — FACILITY INFORMATION
1. Physical address: "NEEDS CHANGE" 2594 Smith Rd. County: Granville
City: Oxford State: NC Zip: 27565-
F SECTION III — BILLING INFORMATION
1. Billing address: 3700 Thompson Woods Ln.
City: Oxford State: NC Zip: 27565-
2. Verify the Applicant does not have any overdue annual fees:
htt s://de .nc. ovfabout/divisions/water-resources/water-resources- ermitslw -e a ments
Pursuant to I SA NCAC 02T .0120(c), permits for renewing facilities shall not be granted if the Applicant or any affiliation has
an unpaid annual fee.
FORM: SFRWWIS-R 02-21 Page 1 of 4

SECTION IV — OPERATION AND MAINTENANCE AGREEMENT
Permit No.: WQ0039827 County: Granville
Permittee: Martin S Thompson Rebecca J. Thompson (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 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 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.
I/We understand the above requirements and agree to these terms as part of the issued permit.
Signature: Date:
Signature: _ _ Date:
't)LLJ a-4
Signature: Date:
Signature: Date:
All deeded property owners shall sign this Operation and Maintenance A eement
FORM: SFRWWIS-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 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 .Q 107 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 I, Item 3 meet the requirements pursuant to 15A NCAC 02T .0105 b ?
® Yes — Skip Attachment B.
❑ No — Submit a delegation fetter pursuant to 15 A NCAC 02T .010b 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 .
® 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 .0116(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 4

Doc ID: 003239280002 Type: CRP
Recorded: 05/09/2018 at 03:49:41 PM
Fee Amt: $26.00 Paqe 1 of 2
Granville County, NC
Kathy M. Taylor Req of Deeds
BK 1685 PG694-695
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE WASTWATER SYSTEM WAIVER
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T .0506(a), .0506(b), .0606(a), .0706(a) AND .1006(a)
I, i 6") CL . e" S certify that I am a deeded owner of the property located at:
Address: Srvld h 01( Fur d °�'� 7 56 S Parcel No.: 1 3 0 100 3(ol 80 9
Citv: State: IV(— Zip Code: � `7�6 �� County:
Furthermore, I certify that I am authorized to make decisions regarding this property, and that I do hereby
agree that the setback distances cited below be granted to the Applicant/Pennittee listed on the following
page.
Q I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from /5V feet to '71;_ feet, thereby allowing the
application of wastewater effluent as near as —4-9- feet from my property line.
❑ 1 understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from feet to feet, thereby allowing the
application of wastewater effluent as near as - feet from my residence.
❑ I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from feet to feet, thereby allowing the
construction of wastewater treatment and storage units as near as _ feet from my property line.
❑ I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from feet to feet, thereby allowing the
construction of wastewater treatment and storage units as near as feet from my residence.
Signature: .c - —- Z' c ems. Date: C Z'
FORM: NDWSW 03-17 Page 1 of 2

Applicant'Permittee: �� ;t 4-1n 71o'Y 5.
Address: ,) S4 j ,, , -� hy2 L', _ Parcel No.:
City: U X i LState: N C Zip Code: County:g c un y,' I IZ
NORTH CAROLINA, COUNTY
r
� r E
I, Y'!S �f �`�, a Notary Public for IA16lkP County, North Carolina,
do hereby certify that J�e k i V1 + & U) Q S personally appeared before me this day
and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the ZE day of t-Y
SEAL j.�R"�?.'•.-•.....,,�•
:r
Signature of Notary Public
My commission expires Vj/'/,)U1 q
Once notarized, this form shall be recorded at the Register of Deeds in the county or
counties in which the described properties are located. A copy of the recorded
waiver shall be sent to the following address:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FORM: NDWSW 03-17 Page 2 of 2