WQ0005165_Application_20240624

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0600 — SEVGLE-F'AM1LY RESIDENCE
WASTEWATER IRRIGATION SYSTEM —RENEWAL
FORM. SFRWWIS-R 02 21
Pursuant to 15A NCAC 02T.0107(bi, if the application does not include allrequired information and the necessary supporting
documentation, the application shall be returned. The application and attachments shall he prepared in accordance with 15A
NCAC 02T .0100, 15A NCAC 02T .06007 and Division Policies. For more information, visit the Water Quality Permitting
Section's Non -Discharge Branch 1 ebsite. The Applicant shall submit an electronic copy of the application and attachments
uploaded as a single Parts ble Document Format (PDF) file to litt_os:/Jedo_es.deo-nr.gnv/Forms/NonDischarue-Branch-S_jihm_ ittal-
F orm-Ver2. or emailed to Nun-Discharge.Renartsrww:ncdenr_ nr if less than Z0 megabytes OM).
SECTION I — APPLICANT INFORMATION
1. Applicant: Daryl L. and Mcchelle C. Clayton
2. Pennit No.: WQ0005165
3. Signature authority: Daryl L. and Mechelle C. Clayton
4. Mailing address: 632 Hillsborough Rd.
City: Timberlake
15. Contact person: Darryl L. Clayton
Primary phone number: [phone] Select
6. Secondary Contact person: Mechelle C. Clayton
Primary phone number (3360364-4U69 Select
Title: Owners
State: NC Zip: 27583
Email:
Secondary phone number. Select
Email: Mechelle_ClaytonQunc.edu
Secondary phone number: [phone] Select
SECTION 11— FACILITY INFORMATION
I. Physical address: 632 Hillsborough Rd. County: Person
City: Timberlake State: NC Zip: 27583
SECTION III — BILLING INFORMATION
1. Billing address: 632 Hillsborough Rd.
City: Timberlake State: NC Zip: 27583
2. Verify the Applicant does not have any overdue annual fees:
littt)s:Ildeo.nc.L=ovlabuutfdivisionslwa ter-resoui- cslH titer-resources-ttenn itslwa -enavm ents
Pursuantto 15A NCAC 02T .0120fc 1,, permits far renewing facilities shall not be granted if the Applicant or any affiliation has
an unpaid annual fee.
FORM: SFRW W1S-R 02-2I Page 1 of 4

SECTION IV — OPERATION AND MAINTENANCE AGREEMENT
Permit No.: WQ0005165 County: Person
Permittee: Darryl L. and Mechelle C_ Clayton (i.e_, all deeded property owners)
The Permittee agrees to operate and maintain the single-family residence wastewater treatment and irrigation system as
follows:
l . 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., c alciumhypochlorite) 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.. (tf
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. (f 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 190 days prior to expiration.
11. Sign and provide a Change of (N nership appIication 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.
IIWe understand the above requirements and agree to these terms as part of the issued permit.
Signature: �'Q�►-- (�/�fp Date: 512412024
Signature:Date: 612412424
Signature: Date:
Signature: Date:
All deeded pranerty owners shall sign this Operation and Maintenance Agreement
FORM: SFRWWIS-R 02-21 Page 2 of

ATTACHMENT A —SITE MAP
Was the facility originally permitted or had a maj or modifica tion issued after September 1, 2006?
❑ Yes — Pursuant to 15A NCAC 02T .0105f d1, submits site map pursuant to the requirements in 15A NCAC 02T .06041d }_ These
requirements are:
❑ A scaled map of the site with topographic con tour intervals not exceeding 10 feet or 25 percent oftotalsite relief and showing
all facility -related structures and fences within the wastewater treatment, storage, and irrigation areas.
❑ Sod mapping units shown on all irrigation sites. l
© The location of all wells (including usage and construction details if available), streams {ephemera], intermittent, and .
perennial), springs, lakes, ponds, and other surface drainage features within 500 feet of all wastewater trea tment, to ,
and irrigation sites.
❑ Delineation of the compliance and review boundaries per 15A NCAC 02L .0107 and .0108, and [ SA NCAC 02T .060 t .
© Setbacks as required by 15A NCAC 02T.0606.
❑ Site property boundaries within 500 feet of all wa stewa ter treatm ent, storage, and irrigation sites.
❑ All habitable residences or places of public assembly within 500 feet of all treatment, storage, and irrigation sites.
F ® No — Skip Attachment A.
ATTACHMENT S — SIGNATURE AUTHORITY DELEGATION
Does the signature authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T _01061h1?
i ® Yes —Skip Attachment B.
❑ No — Submit a deleeatton letter pursuant to l SA NCAC 02T .01.0Glrl authorizing fire 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 sha1I provide a reevaluation of the reduced flow value pursuant to the requirements in 15A
NCAC 02T .01 14(t).
® 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 syste m?
® Yes —Skip Attachment D.
❑ No — Pursuant to 15A NCAC 02T .01161cl, 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. i
ATTACHMENT E — AFFILIATIONS
Are the Permittee's affiliations of record correct? Check affiliations.
IN Yes —Skip Attachment E.
❑ No —Provide the corrected affiliations and their contact information.
ATTACTEVIENT 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

ATTACHMENT G —CIVIL PENALTIES AND OUTSTANDING VIOLATIONS
Daps the Pcrmittee 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
Roes the existing permit include setback waivers?
❑ Yes - Pursuant to 15A NCAC 02T .06061c 1, 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 (12L..0107.
❑ No —Skip Attachment H.
APPLICANT'S CERTIFICATION
1, Mechelle C. Clavton 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 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 .01_2UI61,, thatthe app3i'ant,or any
parent, subsidiary, or 0 th er a ffilia te of the applicant has: notbeen convicted of env ironntentalcrimesunder; not previously abandoned
a wastewater treatment facility without properly closing the facility; not paid a civil penaIty; notbeen 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.0I06(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 § t 43-215.6A and § ! 43-215.6B. any
person who knowingly makes any false statement, representation,orcerti#icatioain any app lic at ion p a okage shallbe guilty o f a Class
2 misdemeanor, which may in�c}lude a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violatio n.
Signature:-�'Ix xI,l` �f1� Date: 6/24/2024
V
THE COPVIPLETED APPLICATION AND ATTACH14ENTS SHALL HE SUBMITTED AS A SINGLE PDF FILE VIA:
Email:
Non-Discha ry e.Re oo its n neden r.,Po v
Laserfiche Upload:
hUus://edo es.dea.nc.g ov /Forms/ No nD! sc lta rLya -Bra nc h-
Submittal-Form-Vet2 -
FORM: S)hRWW1S-R 02 21
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