WQG100003_Accessory Dwelling Units GP Application_20200611

Accessory Dwelling GP Form
State of North Carolina
DWR Department of Eoszronmental Quality
Division of Water Resources
ACCESSORY DWELLL\G UNITS GENERAL, PER-IM A.PPLICATIOti
DIvlslan of Wxter Resources WQG 12-19 & SUPPORTING DOCUIIENI ATION
I. APPLICATION INFORMATION
...........................................................................................................................................
1. Applicant's name:* B. Wallace Design & Construction, LLC
2. Applicant type:* r Homeowner r Authorized
Representative
3. Homeowner's name(s):* Britney Wallace
Homeowner's mailing address:*
Street Address
3200 SANDY CREEK DR
Address Line 2
C7ty State / Province / Region
DURHAM NC
Fbstal / Zip Code Country
27705 United States
Homeowner's contact information:
r Other
Phone Number:* Email Address*
[phone] [e-mail]
(xxx)xxx-xxxx
II. PROJECT INFORMATION
11 ...... ...... ...... ..... .... ... .. ......... .................... ....................... ......... ........ ......... ..................
1. Application/Project Status:*
r Proposed (new Certificate of Coverage)
r Existing Permit/Project (Certificate of Coverage previously issued for this address)
2. County where project is Durham
located:*
*** If the primary residence is existing please provide the address. If the primary residence is new construction, please
either provide the address OR provide the latitude and longitude of the parcel.
3. Address of project primary residence:

Street Address
410 Jerome Road
Address Line 2
city
Durham
Postal / Zip Code
27713-1290
State / Province / Pegion
NC
Country
Us
Latitude: 35.94165709999999 Longitude:-78.893056
4. Parcel ID (if applicable):* 220864
(or parcel ID to closest downstreamsew er)
III. GENERAL REQUIREMENTS
1. Is the primary residence, as defined in the General Permit definitions, existing or proposed?*
* Existing (please complete Item 2 below)
* Proposed (please complete Item 3 below)
3. If the primary residence and the ADU/ARB are both new construction, please provide a description of the
proposed sewer services (select one):*
* Both shall be served by a gravity sewer of 4-inches in diameter or greater
r The primary residence shall be served by a gravity sewer of 4-inches in diameter or greater, with the ADU/ARB
served by pump station and force main
* The primary residence shall be served by a pump station and force main, with the ADU/ARB served by a gravity
sewer of 4-inches in diameter or greater, which ties into the pump station wet well
r Other
4. Describe the size of the primary residence and ADU/ARB:
Number of bedrooms* Total Daily Flow a*
Size of the Primary Residence 3 360
(120 gallons/day per bedroomx no. of bedroorrs)
Size of ADU/ARB 1 120
(120 gallons/day per bedroomx no. of bedrooms)
a. See 15A NCAC 02T.0114(b), (d), (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e., minimum flow per dwelling; proposed
unknown non-residential development uses; public access facilities located near high public use areas; and residential property located
south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined in G.S. 42A-4).
b. If the primary residence is a duplex structure, please include the total number of bedrooms for the entire building.
IV. SETBACKS & SEPARATIONS FOR NEW CONSTRUCTION ONLY - (02B .0200 & 15A NCAC 02T
.0305(fl):
......... ...... ...... ..... ..... ... .. .. ......... ......... ......... ......... ......... ......... .........
1. Does the project comply with all separations found in 15A NCAC 02T .0305(f) & (g) *
r Yes
r No
➢ 15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:

5etbac:{ ?arameter*
Separation Re wired
Storm Set;ers and otherutilitie� not li�_ed helm vertical
)4 inches
Water mains (vertical -water a;-er }e . er including iu benched trenches)
18 inches
Water mains (horizontal)
10 feet
Reclaimed %r ater lines "rei#ical - reclaimed over stwer
18 inches
Reclaimed n ater lines "horizoutal - reclaimed over Sewer
2 feet
*Any private or public water supply source, including any wcH11 WS-I waters of C1a�s
I or Class II impounded resen airs used as a source of drinking
100 feet
"Waters classified WS (except WS-I or WS-V)_ B, SA, DRW: HQI _ or 5B from
normal high i.iater (or tide cic; ation) and 3vedan& 'see item IY_2
50 feet
"Any other Stream: lake, impoundment_ or around water lowering and surface
drainage ditches L
10 feet
Any building foundatiou
5 feet
Any basement
10 feet
Top slope of embankment or cuts of 2 feet or mare vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any sivm=g pools
10 feet
Final earth grade rerbcal
34 inches
➢ 15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(f) cannot be achieved
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
2. Does the project comply with separation requirements for wetlands?*
r Yes r No r N/A
➢ See the Division's draft separation requirements for situations where separation cannot be meet
➢ No variance is required if the alternative design criteria specified is utilized in design and construction
➢ As built documents should reference the location of areas effected
3. Does the project require coverage/authorization under a 404 Nationwide or individual permits or 401 Water
Quality Certifications? *
r Yes r No
➢ Information can be obtained from the 401 & Buffer Permitting Branch
4. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)?*
r Yes r No
Per 15A NCAC 0210105(c)(6), directly related environmental permits or certification applications are being prepared, have been applied
for, or have been obtained Issuance of this permit is contingent on issuance of dependent permits (erosion and sedimentation control
plans, stormwater management plans, etc.).
V. CERTIFICATION STATEMENTS:
....... ...... ...... ..... ..... ... .. .. ......... ......... ......... ......... ......... ......... ..................
1. Is the primary residence a single family or duplex structure?
r Yes r No
2. The parcel on which both the primary residence and the ADU/ARB are located is deed restricted in perpetuity
from subdivision of the parcel in any form that would result in the separation of the primary residence and the
ADU/ARB to discrete parcels. A copy of the completed and filed deed with included restriction or a copy of the
complete and separately filed deed restriction must be uploaded for this application to be complete. Deeds
which are unsigned/not filed or do not include the restriction will not be accepted.*
r Yes
r No
Dee d\Deed Restriction 410 Jerome Deed Restriction RECORDED. pdf 83.85KB
Upload:* PDFpnly

3. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump
Stations and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as
applicable?*
r Yes r No
r N/A (primary residence is existing)
Links to 15A NCAC 02T, the Ninimum Design Criteria for the Permitting of Pump Stations and Force Mains (latest version), and
the Gravity Sewer Mnimum Design Criteria (latest version).
4. Is either the primary residence or the ADU/ARB served by a pump station/force main, with the other structure
served by gravity sewer?*
r Yes r No
r NW (both are gravity)
5. Is the tie-in from the ADU/ARB's new sewer line to the primary residence's existing sewer located outside of
the existing primary residence's basement or crawl space, and is not located under the foundation?*
r Yes r No
r NW (all new construction)
6. Is the tie-in from the ADU/ARB's new sewer line to the primary residence's existing sewer located as far as
practicable from the existing building and from any natural features such as streams, ponds, or wetlands; and as
far as possible from any other utilities, including wells used for irrigation or drinking water?*
r Yes r No
r NW (all new construction)
If the answers to any of the above statements is "No," this project is ineligible for coverage under this General Permit, and must
proceed through either the Fast Track or standard sewer permitting processes.
Applicant's Certification per 15A NCAC 02T .0106(b): I,
Britney S. Wallace
(Signature Authority's name from Application ftem1.3.)
attest that this application for the primary residence and ADU/ARB located at
410 Jerome Road, Durham NC 27713
(parcel address or latitude/longitude)
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 are not completed and that if all required supporting documentation and attachments are not included, this application package
is subject to being returned as incomplete. I understand that any discharge of wastewater from this non -discharge system to surface waters
or the land will result in an immediate 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.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6A 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 rme not to exceed
$10,000 as well as civil penalties up to $25,000 per violation.
Signature:
10�r4 451' �
Submission Date: 6/11/2020
filled out automatically

Initial Review Form
Does this application meet the requirement to issue a COC?*
Yes
No
ID#: * WQG100003
W All information in BIMS has been filled out.
Reject Email Comments
Please put in comments that need to be added to the email sent out.
Reviewer: Litzenberger, Kristin S
Reviewer Email: Kristin. [e-mail]
Review Date: 6/17/2020

Book8907 - Page 442 Page 1 of 2
REGISTER OF DEEDS
Sharon A. Davis
Durham County, NC
2020Apr 13 03:32:43 PM
BK:8907 PGA42-443
DECLARATION
FEE: $26.00
INSTRUMENT # 2020011488
APRILJ
IIIIIIIIII IIIIIIIIII II III
STATE OF NORTH CAROLINA t>r2 fpoMe CL 61 T- r'PvY^ -t°
COUNTY OF DURHAM Lisa M Logan, Attorney
100 E. Parrish St., Ste. 400
Brief Description for Index: 410 Jerome Road Durham NC Durham, NC 27701Parcel ID: 220864
DECLARATION OF DEED RESTRICTIONS
THIS DECLARATION OF DEED RESTRICTION (the :'Declaration") is made and entered into
as of this `day of rn a Bch. 2020.
WHEREAS, B. Wallace Design & Construction, LLC is the Owner ("Owner") of a certain tract
of real property, more particularly described as:
Being all of Lot 117 on the plat entitled EMORYWOOD ORCHARDS Phase 3 now on file in the
Office of the Register of Deeds of Durham County in Plat Book 199 at Pages 279-280, reference
to which is hereby made for a more particular description of and incorporated herein by reference
(the "Property") with the address of: 410 Jerome Road Durham North Carolina, Parcel ID:
220864;
WHEREAS, the Property does have or will have built upon it an Accessory Dwelling Unit
("ADU") or Accessory Residential Building ("ARB") that shares a private sewer line with the
primary residential house; and
WHEREAS, as a condition of issuing a certain requested permit to Owner, the County of
Durham ("Durham") has required and Owner has agreed to restrict the Property as set forth
herein below.
NOW THEREFORE, in consideration of the mutual covenants and understandings set forth
herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby
acknowledged, Owner, hereby represents, covenants, warrants and agrees_ to the following:
The Restriction. The primary residential house that is situated upon this real estate may

Book8907 - Page 443 Page 2 of 2
not be subdivided from or separated from, in any manner, the ADU/ARB so long as the primary
residential house and the ADU/ARB share a connected private sewer line; and
2. Restriction to Run With the Land. The restriction set forth herein (a) shall be deemed a
restriction and a covenant running with the land in perpetuity and shall pass to and be binding
upon Owner, the Owner's heirs, successors and assigns in title to the Property and all subsequent
owners of the Property and (b) are not merely personal covenants of the Owner.
Governing Law. This Declaration shall be governed by the laws of the State of North
Carolina.
IN WITNESS WHEREOF, the Owner(s) has executed this Declaration on the date first written
above.
B. WALLACE DESIGN & CONSTRUCTION, LLC
By: Gp✓�
Britney S allace, Manager
STATE OF V01" d 1, r Q,
COUNTY OF ,)4h10-m
541ra ?Q.l, cias. 6*)) o1-\ , a Notary Public for the County of
and the State of North Carolina, do hereby certify that the following person
personally appeared before me this day, acknowledging to me that she voluntarily signed the
foregoing document for the purpose stated therein and in the capacity indicated: Britney S.
Wallace, Manager of B. Wallace Design & Construction, LLC, a North Carolina Limited Liability
Company.
Witness my hand official notarial seal, this the 3 Q day of M0,r6,A , 2020.
My Commission Expires: V - 074 - Day Notary Public
Printed name of Notary: - r , 5�� �GtiQ�aS C�lw►'� M Cristina Paredes Cnlon
Notary Public
Durham County, NC