WQ0016122_Application_20200601

State of North Carolina
DWR Department of Environmental Quality
Division of Water Resources
SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEM RENEWAL
Division of Water Resources FORM: SFRWWIS-R 09-18
This form is for renewal without modification for single-family residence wastewater irrigation system permits.
For more information, visit the Water Quality Permitting Section's Non-Dischar a Branch.
PERMIT INFORMATION:
1. Permit No.: WQ0016122
2. Permittee: 011en M. and Sylvia M. Lane (i.e., deeded property owners)
3. Signature authority's name: 011en M. and Sylvia M. Lane (i.e., deeded property owner or legal representative) [15A NCAC 02T
.0 06b]
4. Physical address of residence with treatment/irrigation system: 64 Pin Oak Ct.
City: Chapel Hill State: NC Zip: 27517-_ County: Chatham
5. Permittee's mailing address (if different from above): PO Box 52058
City: Durham State: NC Zip: 27717-
6. Permittee's contact info at
,on: ✓.' '+J f�
Primary Contact: Phone number: (-� Primary email address:` L
Secondary Contact: Z
Phone number-"— Secondary email address:
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7. Has the treatment/irrigation system been installed? ® Yes or ❑ No 6
Applicant's Certification per 15A NCAC 02T .0106(b):
I, C ...� 'my —knowledge.
,attest that this renewal application has been reviewed by me, and is
accurate an cod fhe best of complete znyknowledge. I understand that any unauthorized discharge of wastewater from this non -discharge
system 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 abandoned, are compliant with any active 9pliance schedule, and does not have any overdue annual fees.
Date: FSEAMM
THE COMPLETED APPLICATION SHALL BE SUBMITTED TO:
By U.S. Postal Service: By Courier: By Email:
Non -Discharge Branch Non -Discharge Branch— Archdale 942W Non-Discharge.Reports(ancdenr.go_v_
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

1
DWR
Division of Water Resources
Permit No. WQ0016122
State of North Carolina
Department of Environmental Quality
Division of Water Resources
SINGLE-FAMILY RESIDENCE WASTEWATER IliRIGATION SYSTEM
OPERATION AND MAINTENANCE AGREEMENT
FORM: SFRWWIS-O&M 09-18
Permittee: 011en M. and Sylvia M. Lane (i.e., all deeded property owners)
County: Chatham
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)
S. 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 ap lip cation 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 requirements and agree to these terms as part of the issued permit.
Signature: �tDate: 4-757
Signature: Date:
IX f `' ' ��
Signature:
Signature:
Date:
Date:
All deeded property owners shall sign this Operation and Maintenance Agreement
FORM: SFRWWIS-O&M 09-18 Page 1 of 1