WQ0018419_Application_20200615

+JWK Department of Environmental Quality
Division of Water Resources
1WjQ�n �f Wafer Resnarres i�[C1N-1718CFIARGF PERMIT OWNER5FIFPJI4AivIR CHANGE
A�CSTRUCTIONS FOR. FORM: NDPONC 06-I6 & SUPPORTING DOCI M NTATIOIN
This form is for ownership changes or name changes of a non-diacharge system permit. Please note that "Permittee"
references the existing permit holder, and that "Applicant" references the entity applying for the ownershiplaame change.
Far more trgbrmariDn, uisir the Water Quality Permitting Section's Non -Discharge Permitting Unit website
A. Non -Discharge Permit Ownership/Name Change (FORM. NDPONC 06-16) Application (Ail Applications):
�• Submit an original completed and appropriately executed Non -Discharge Permit OwnershiplName Chaogc (FORM: NDPONC
06-16) application.
© The Existing Permittee'-s Certification shall be signed in accordance with 15A NCAC 02T .01061). Per I5A I r 02T
01 tj an alternate person may be designated as the signing official if a delegation letter is provided from a person who
meets the criteria in i 5A CAC 02T .0106 , tq 4
ElThe Applicant's Certification shall be signed in accordance with I5A NCAC 02T .0100021. Per 15� *0 r kr
ity
alternate person maybe designated as the sign iog official if a delegation letter is provided from a person who gels fie dtexlEL
in 15A NCAC 02T .4ji6Lbj. {�
t:" nn��
E. E3+�sting Permit (All Applications): /_Ut.'
�[ Submit a copy of the most recently issued permit- Winston-Salem
C. Property Ownership Documentation (All Applications): P'egional C-f. - .
➢ Per 15A NCAC 02T .0504 o 15A NCAC 02T .0604(e); 15A_NCAC_02T_.0 04 f , 15A 1YCAC 021 .0804, I5A NCA_C,-02T
1004 d I5A NCAC 02T .1104(d)( j7 , 15A NCAC 021.1104 e M, 1SA NCAC 021J.0201(e) or 15A NCAC 0213 ,0202 ,
the,,Applicant shall demonstrate they are the owner of all property containing.the non -discharge system facilities:
Cd . Legal documentation of ownership (i.e., CIS, deed or article of incorporation), or
❑ Written notarized intent to purchase agreement signed by both parties with a plat or survey map, or
❑ Written notarized lease agreement that specifically indicates the intended use of the property and has been signed by both•
parties, as well as a plat or survey map. Lease agreements shall adhere to the requirements of 15A NC&C 02L .0107.
D. Certificate of Public Convenience and Necessity (All Applications where the Applicant is a Frivately•Owned Public Utility):
❑ Per 15A NCAC 02T .0 11 5a l , provide one copy of the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commis i n demonstrating the Applicant is authorized to hold the utility franchise for the area to be served
by the uon-discharge system.
E. OperationaI Agreements (All Applications where the Applicant is a Home/Property Owners' Association or Developer of lots to
be sold):
➢ Aome11'ronerty owners' Assoc'ai tions
❑ per 15A NCAC 02T .0115 e ,submit an original properly executed Operational Agreement (FORM: HOA}.
❑ Per 15A NC C 021 ,0115Lcl, submit an original proposed or approved Articles of Incorporations, Declarations and By-
laws.
➢ De CIO ers_of_ lots to be sold
Per I5A NCAC 02T .6115 , submit an original of the properly executed operational AQreeme_rit (FORM:_DEV),
F
O eration and Maintenance Agreement (All Applications for Single -Family Wastewater Irrigation Systems):
Per I5A NCAC 02T .0604ft submit an original of a notarized Operation and Maintenance Agreement [FORM: SFRWIVIS
DAM that has been signed and dated by all deeded property owners.
THE. COMPLETED APPLICATION AND SUPPORTING DOCUII'YNTATION SHALL BE SUBMITTED TO:
NORTH CAROLINA DEPARTMENT OF ENVIRONMYNTAL QUALITY
DIYI5ION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE BRANCH
By U.S. Postal Service:
1617 MAIL SERVICE CENTFR
RALEIGH, ;VORTH CAROLINA 27699-1617
By Courier/Special Delivery;
512 N. SALLSBURY ST.
ItAl,PIGH, NORT11 CAROLINA 27604
TELEPHONENIYIBE:R. [phone]
RUCTIONS FOR FORM: NDPONC 06-16 & SUPPORTING DOCUMENTATION
Page i of I

DWLslan of Water
Department of Environmental (Reality
Division of Water Resources
NON -DISCHARGE PERMIT OWN1zRSN ME U g CHAN0 -16
E
ReCF=
1. EXISTING PEptMn"EINFORMAT�ON' ' k pt)AI CAYDlInc. L vStn-5
1. Permittees name:�1 xi' � « O ��� f,-:r,,Y 0 fi 21320
2. Signature authority's name: per 15A NCAC 02T .0 06 Title: Winston-Salem
3. Permittee's mailing address: zq 11`l, i+ Regions Offi
City:i! <:I140state: N L zip: _Jj- - .1AS � au i cAti"`
4. Permittee's contact inforniatiwt: Phone number: i3_z' ') �A- °� 2V Email Address:
5. Demonstration of historical consideration for permit approval - 15A NCAC 02T .0120'
Has the Permittee or any parent, subsidiary or other affiliate exhibited the following?
a.. Has been convicted of �yironmental crimes under Federal law or G.S. 143-215,6B? ❑ Yes or 9No
b. Has previously abandoned a wastewater treatment facility without properly closing that facility? Yes °r �NO
c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes or dNo
d. Is non -compliant with an existing non -discharge permit, settlement agreement or order? ❑ Yes or L ] NO
e Has unpaid annual fees in accordance with l5A 2T CAC 0.0105 e 2 ? '�IYes or �o
IL FACILnT INpOR1vIATION:
1. Facility name: __16k �� �, QN 'A
2. Faciiity,s physical address: ZGZ
CiT, �fKC state: �( zip: 2'13�L County.; fllahutn
M. PER?MT INFOR-I ATION:
1. Existing permit number: WQ04 t 1`1 and most recent issuance date:
tQ-VAY1'1,Iv� re5�ce W> V`lGl lyN��C
2 ExLting permit type: Select S, -
3. Reason for the permit application: Select (,VnAnol�
4. Has the facility been commneted? [lYes or No SVP"`k
IV. APPLICANTWORMATION:
1. Applicant's name: SaM1 . VO 'P�_
AN2. Signature authority'saameh CA Uz Title;
3. Applicant's mailing address: �53Z -TbM
city&�r State: N L Zip: � k2- k C l A A
4. Applicant's contact information; Phone number: ("I __-HD dn�q Email Address:�MM
5, Demonstration of historical consideration for permit approval - 15A NCAC 02T .0120:
Has the Applicant or any parent, subsidiary or other affiliate exhibited the following?
a- Has been convicted of envirotunental crimes under Federal law or G.S. 143-215.6B? ❑ Yes or O No
b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or El"No
c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes or &?No
d- Is non -compliant with an existing non -discharge permit, settlement agreement or order? ❑ Yes or ['No
e. Has unpaid annual fees in accordance with 1 SA NC 02T .0 105 e ? ❑ Yes of 9No
FORM: NDPONC 06-16 Page i of

rPermittre's Certification per r15A NCAC 02T .010b(l: C l 'l-'% �� eB f that this. application for
(signature Authority's name & title from A Iication7Item I.
(Facility name from Application Item 11.1.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that prior to reissuance of the permit
into the Applicant's name, any discharge of wastewater from this non -discharge system to surface waters or the land will 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 the existing permit be violated. I also understand that if all required parts of this
application package are not completed and that if all required supporting information and attachments arenot included, this application
package will be returned as incomplete. I further certify that the existing pemuttee or any of iliate '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 do not have any overdue annual
fees per 15A N 'AC C2T.0l OS e .
MOTE - In accordance with General Statutes 143-215.d and ]43 27 S.Gi3 any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a'Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature: vY2 l� 1 ! Date:
Applicant's Certification per 15A NCAC 02T .010�:
attest that this application for
(Signature Authority's name & title from Application Item IV.2.)
- (Facility name from Application Item 11.1.}
has been reviewed by the and is accurate and complete to the best of my knowledge. I understand that after reissuance of the permit
into the Applicant's name, any discharge of wastewater from this non -discharge system to surface waters or the land will 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
package are not completed and that if all required supporting information and attachments are not included, this application package
will be returned to me as incomplete, I further certify that the Applicant or any affiliate 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 do not have any overdue annual fees per 15A
NCAC 02T .0105(g).
NOTE - In accordance with General Statutes 143-215.6A and 143-215.6B any Person who knowingly makes any false statement -
representation, or certification in any application package shall he guilty of a' Class 2 •misdemeanor, which may include a fine not to
exceed $1D 00 as well as civil penalties up to $25,000 per violation.
signature: -� Date: 12- as
FORK NIDPONC 06-16
Page 2 of'2

f` u r��Nartrr�erit us
Environmental Quality
Received
F'AY 0 6 2020
Winston-Salem State of North Carolina
Regional Office Department of Envirorewental (duality
llivision of Water Resources
SINGIS,PAMILY RESIDRNCE WASTEWATER MMGATION SYSTEM RENEWAL
DIvLsion of Water Kesourtes FORM; SFRwWIS-R 09-18
This form is for renewal without modification for sill glc- family residcnce wastewater irrigation system permits.
For more information, visit the Water L?uahty Permitting &ctlan's Norr-D!s ha_ e r
PER1%GT INFORMATION:
1, Permit No.: WQ0G 1 1-i �y
�
2. Permittee: (i.e., deeded property owners) S M h ��'
3. Signature authority's name: (i.e., deeded property owner oo gal representative)A CA OAT . 106[h�)
4. Physical address of residence with treatmenthrrigation system: 3 � Uhl
Coon � ��'�'l �`n `-'e-'
City: & . Ytc State: � zip:2xJ County:
S. permitpw's mail'mg address (if different from above): -
City: State: Zip: -�
6. Permittee's contact information: .,� iLfo•C O tr
r _ �,.R- r: Ptimar3' etnall address; 2 �'�
Primary Contact: Safah t` 1 Phone number
secondary Contact: tL\,�n 0�)C& Phone number: ffi! L) L�'J Secondary email address:
7. Has the treatment/irrigation system been installed' V'Yes or [] No
A plicant's Certification per 15A NCAC 02T .0114�:
attest that this renewal application has been reviewed by me, and is
atcr from,
d discharge ofwastew
accurate and complete ischarge
to the best of my knowledge- in an nunderstandnaction that may incthat any lude civil penalties, injunctive relief, andtois Tcriminal
system to surface waters or the land may result
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
PYhRii_oed or abandoned, arc compliant with any active compliance schedule, and does not have any overdue annual fees.
5i ature•
4ti l�. an Date: � A
113
TUE COMPLETED APPLICATION SIIALL BE SUBNDT rEU TO:
B ourier Sv Email,
)6 Us. Postal C
Postal -service: ' �: � - - a �
Non -Discharge Branch Non -Discharge Branch - Archdale 640D lion-Dischar e.Re its ncdenr. oy
512 N. Salisbury
1617 Mail Service Center Rol
Raleigh, NC 27699-1617 Raleigh, NC 27604
TELEPHONE NUMBER. [phone]
i

ADWLSIOU of Water Resource
Permit No. WQOO tlb1c)
h �_ uepartment of
Environmental quality
Received
MAY Q 6 2020
Winston-Salem
Regional Office
State of North Carolina
Department of Environmental Quality
Division of Water Resourees
SINGLE-FAMILY RESIDENCE WASTIEWATRR IRRIGATION SYSTEM
OPERATION AND MAINTFNANCE AGREEMYNT
FORM: SFRWWIS-O&M 09-18
�S?(0'�k
Permittee: _____ (i.e., all deeded property owners)SGl Mn �]o�►�nr�
County: �1oti11't m _
The Permittee agees 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. (rf applicable)
4. Inspect the ultraviolet disinfection unit weekly. Clean or replace the lamps and quartz sleeves as needed. (if
applicable)
S. Inspect ail 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.
4. 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 0 BMW a lieation 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: Date. ��
Signature: Date:
S re: Date: