WQ0005440_Renewal Application_20200615

Initial Review
INITIAL REVIEW
Reviewer Thornburg, Nathaniel
Is this submittal an application? (Excluding additional information.)*
r Yes r No
Is this a complete
application?* Complete App Date
r Yes r No 06/15/2020
Project Number* WQ0005440
Applicant/Permittee Timothy J. Parker
Applicant/Permittee 3520 Laws Store Rd. Hurdle Mills NC 27541
Address
Is the owner in BIMS?
r Yes r No
Owner Type
Facility Name
County
Fee Category
Single -Family Residence
Signature Authority
Individual
3520 Laws Store Rd. SFR
Orange
Signature Authority Title
Signature Authority Email
Document Type (if
non -application)
Email Notifications
Does this need review by the hydrogeologist?*
r Yes r No
Regional Office
CO Reviewer
Is the facility in BIMS?
r Yes r No
Fee Amount
0

Admin Reviewer
Below list any additional email address that need notification about a new project.
Email Address
Comments to be added to email notification
Comments for Kendall
Comments for RO
Comments for Reviewer
Comments for Applicant

Submitted Form
Project Contact Information
Rease provide information on the person to be contacted by MB Staff regarding electronic subnittal, confirmation of receipt, and other issues.
........................................................................................................................................................................................................................................................................................................................................................................
Name * Timothy J. Parker
Email Address*
bibianaparker1 @gmail.com
Project Information
.......................................................................................
Submittal Type* r New Permit Application
r Renewal
r Annual Report
r Other
Permit Type * r Wastewater Irrigation
r Other Wastewater
r Closed -Loop Recycle
r Single -Family Residence
Wastewater Irrigation
Is a paper copy of the application being submitted?
r Yes r Nor N/A
Permit Number WQ0005440
currently has project
Applicant\Permittee * Timothy J Parker
Phone Number*
919568-9804
Applicant/Permittee 3520 Laws Store Rd. Hurdle Mills NC 27541
Address*
Facility Name * 3520 Laws Store Rd. SFR
r Modification (Major or Minor)
r Additional Information
r Residual Annual Report
r High -Rate Infiltration
r Reclaimed Water
r Residuals
r Other
Please provide comments/notes on your current submittal below.
Please attach all information required or requested for this submittal to be review here.
Application Forma Engineering Rans, Specifications, Calculations, Etc.)
SFRWWIS-R-09-18 Timothy J Parker 3520 Laws
914.55KB
Store Rd.pdf
upload only 1 PDF document. NL@iple documents must be combined into one FCF file.

For new and modification permit applications, a paper copy may be required. If you have any questions
about what is required, please contactthe reviewer or Tessa Monday. If a paper --polka*-ion is required,
be advised, applications accepted' far pre -review until both the paper and eIect-c-,i_ co1)ies nave been
received. The paper copy shall include the following:
o Application Form
o All relevant attachments (calcs, soils report, specs, etc.)
o One full-size engineering plan set
o One 11x17" engineering plan set
o One extra set of specifications
o Fee (if required)
MallinE address:
❑iuision of Water Resources1 Division of Water Resources
Non -Discharge Branch I Non -Discharge Branch
1617 Mail Service Center 1 Aft: Nathaniel Thornburg, 91° Floor, Cfice #942W
----------------------------------------------------------- -----------------------------------------
Raleih, NC 27699-1617 512 N. Salisbury St.
Far questions or problems contact Tessa Monday [e-mail] or 919.707.3560.
* W By checking this box I acknowledge that I understand the application will not be accepted
for pre -review until the paper copy (if required) and fee (if required) have been received by
the Non -Discharge Branch. I also confirm that the uploaded document is a single PDF with
all parts of the application in correct order (as specified by the application).
Signature
Submission Date 6/13/2020

State of North Carolina
Department of Environmental Quality
DWR 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 -Discharge Branch.
PERMIT INFORMATION:
1. Permit No.: WQ00
2. Permittee: (i.e., deeded property owners)
3. Signature authority's name: (i.e., deeded property owner or legal representative) [15A NCAC 02T .0106(b)]
4. Physical address of residence with treatment/irrigation system:
City: State: NC Zip: - County: Select
5. Pemittee's mailing address (if different from above):
City: State: Zip: -
6. Permittee's contact information:
Primary Contact: Phone number: O - Primary email address:
Secondary Contact: Phone number: O - Secondary email address:
7. Has the treatment/irrigation system been installed? ❑ Yes or ❑ No
Applicant's Certification per 15A NCAC 02T .0106(b):
I, , attest that this renewal application has been reviewed by me, and is
accurate and complete to the best of my knowledge. 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 compliance schedule, and does not have any overdue annual fees.
Signature:
Date:
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.Reportsk cdenr.gov
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
DWR Division of Water Resources
SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEM
Division of Water Resources OPERATION AND MAINTENANCE AGREEMENT
FORM: SFRWWIS-O&M 09-18
Permit No. WQ00 County: Select
Permittee: (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.
We understand the above requirements and agree to these terms as part of the issued permit.
Signature:
Signature:
Signature:
Signature:
Date:
Date:
Date:
Date:
All deeded property owners shall sien this Operation and Maintenance Agreement
FORM: SFRWWIS-O&M 09-18 Page 1 of 1