WQ0012412_Application_20190326

State of North Carolina
RECEIVEDWOEQIDWR Department of Environmental Quality
Division of Water Resources
ImR
SINGLE-FAM"Rf"5E WASTEWATER IRRIGATION SYSTEM RENEWAL
Dlvllsl1ae of Water Resources FORM: SFRWWIS-R 09-18
This form is for renewal without modification O&JUiAy residence wastewater irrigation system permits.
For more information, visit the Water Quality Permitting Section's Non -Discharge Branch.
PERMIT INFORMATION:
Q
1. Permit No.: W 00-1 V/x
2. Permittee: (i.e., deeded property owners) o4 �"'r"'✓
°
3. Signature authority's name: (i.e., deeded property owner or legal representative) [15A NCAC 02T .010 b ]
4. Physical address of residence with treatment/irrigation system:
City: 5,AO�i State: NC Zip: - County: AIA
5. Permittee's mailing address (if different from above):
City: State: Zip:
6. Permittee's contact information:
Primary Contact: S,4A)9qFr Phone number: ) Primary email address:
Secondary Contact. hfjqpffe number: Ay
r. ��r Secondary email address:
7. Has the treatment/` igation system been installed? 1—IR-les or ❑ No
Ap eu�and
—Ot's Certification per 15A NCAC 02T .0106 b :
I, (\ , attest that this renewal application has been reviewed by me, and is
c aomplete to the best o my knowledge. I understand that any unauthorized discharge of wastewater from this non -discharge
stem to surface waters or the land may result in an enforcement action that may include civil penalties, injunctive relief, and/or criminal
prosecution. I will make no claim against the Division of Water Resources should a condition of this permit be violated. I also
understand that if all required parts of this application are not completed, this application may be returned to me as incomplete. I further
certify that the Applicant or any parent, subsidiary, or other affiliate of the Applicant has not been convicted of an environmental crime,
has not abandoned a wastewater facility without proper closure, does not have an outstanding civil penalty where all appeals have been
exhausted or U"one�;lare compliant with any active compliance schedule, and does not have any overdue annual fees.
Signature: Date: J — / <1
THE COMPLETED APPLICATION SHALL BE SUBMITTED TO:
BA, U.S. Postal Service: ✓ By Courier: By Email:
Non -Discharge Branch Non -Discharge Branch — Archdale 640D Non-Discharge.Re ortsfi6ncdenr.2ov
1617 Mail Service Center 512 N. Salisbury St.
Raleigh, NC 27699-1617 Raleigh, NC 27604
TELEPHONE NUMBER: [phone]
FORM: SFRWWIS-R 09-18 Page 1 of 1

State of North Carolina
Department of Environmental Quality
Division of Water Resources
SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEM
Dl mon of Water Resources OPERATION AND MAINTENANCE AGREEMENT
p;CnvPn1N+~.nFQIDWR FORM: SFRWWIS-O&M 09-18
MAR 2 6 Z019 county: /A ,
Permit No. WQ00) a y,o�
Non -Discharge
Permittee: (i.e., all deeded property owners) Permitting Unit
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.
We understand the above
Signature:
Signature:
Signature:
Signature:
r`, - =-- ed permit.
Date: Z
Date: 7
Date:
Date:
All deeded proper" owners shall sign this Opera and Maintenance A reement
FORM: SFRWWIS-O&M 09-18 Page 1 of 1

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEMS
aaw�OPERATION AND MAINTENANCE AGREEMENT
PD[onof Water Resources FORM: SFRWWIS O&M 08-13
of Water Res
Permit No. n n ),2 /��o� County: Iq
Property owner(s) as appearing on the recorded deed: r
Mailing address: f E p�y7iv
e�pCwP _ � 7
Facility address: 414�r_d 1,'�) Er Y 1 7,2_ F 57
Irrigation Method: WSPRAY ❑ DRIP
I / We agree to operate and maintain the single-family residence wastewater treatment and irrigation system as follows:
1. The Permittee is responsible for the operation and maintenance of the entire wastewater treatment and irrigation
system including, but not limited to, the following items:
a. The septic tank shall be checked annually and pumped out as needed.
b. The septic tank effluent filter shall be checked and cleaned annually.
c. Accessible sand filter surfaces shall be raked and leveled every six months and any vegetative growth shall be
removed manually.
d. [] The tablet chlorinator shall be checked weekly. Wastewater grade tablets (calcium hypochlorite) shall be
added as needed to provide proper chlorination (pool chlorine tablets shall not be used), OR
❑ The ultraviolet disinfection unit shall be checked weekly. The lamp(s) and quartz sleeve(s) shall. be
cleaned or replaced as needed to ensure proper disinfection.
e. All pump and alarm systems shall be inspected monthly.
f. The irrigation system shall be inspected monthly to ensure that the system is free of leaks, that all irrigation
equipment is operating as designed, that vegetative growth does not interfere with the system inspection or
operation, that the soil is assimilating the disposed treated wastewater with no visible runoff or ponding, and
that no objectionable odors are being generated.
2. Failure to pay the annual fee shall be cause for the Division to revoke the permit pursuant to 15A NCAC 02T
.0105(e)(3).
3. The Permittee's failure to properly operate this system is subject to a penalty up to $25,000 per day.
4. Failure to meet the permit conditions or violation of the State's surface water or groundwater regulations may void
the permit.
All owners ap pearingon the legally recorded propertv deed shall sign this Operation & Maintenance Agreement
I / We understand the above
Owner Signature:
Owner Signature:
and agree to these terms as part of the issued permit.
Date
Date
FORM: SFRWWIS O&M 0843 Page 1 of 1