WQ0021351_Renewal Application_20210212

Initial Review
Reviewer Thornburg, Nathaniel
Is this submittal an application? (Excluding additional information.)*
r Yes r No
Permit Number (IR)* WQ0021351
Applicant/Permittee Mark A. and Karen E. Kloefkorn
Applicant/Permittee Address 105 Folly Creek Road Morrisville NC 27560
Is the owner in BIMS? r Yes r No Is the facility in BIMS? r Yes r No
Owner Type Individual
Facility Name 105 Holly Creek Rd. SFR
County Wake
Fee Category Single -Family Residence Fee Amount $0
Is this a complete
application?*
r Yes r No Complete App Date 02/12/2021
Signature Authority
Signature Authority Title
Signature Authority Email
Document Type (if non -application)
Email Notifications
Does this need review bythe hydrogeologist?* r Yes r No
Regional Office
CO Reviewer
Admin Reviewer
Below list any additional email address that need notification about a new project.
Email Address
Comments to be added to email notfication
Comments for Kendall
Comments for RO

Comments for Reviewer
Comments for Applicant

Submittal Form
Project Contact Information
Rease provide information on the person to be contacted by NM Staff
Name * Mark Kloefkorn
Email Address*
[e-mail]
electronic subnittal, confirmation of receipt, and other correspondence.
Phone Number*
919-345-0935
Project Information
...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Application/Document Type* r New (Fee Req ui red)
r Modification - Major (Fee Required)
r Renewal with Major Modification (Fee
Required)
r Annual Report
r Additional Information
r Other
O Modification - Minor
G Renewal
C GW-59, NDMR, NDMLR, NDAR-1,
NDAR-2
r Residual Annual Report
r Change of Ownership
We no longer accept these monitoring reports through this portal. Please click on the link below and it will take you to the correct form.
https://edocs.deq.nc.gov/Forms/NonDischarge_Monitoring_Report
Permit Type:*
r Wastewater Irrigation
r High -Rate Infiltration
r Other Wastewater
r Reclaimed Water
r Closed -Loop Recycle
r Residuals
r Single -Family Residence Wastewater
r Other
Irrigation
Permit Number:*
WO0021351
Fbs Current Existing permit number
Applicant/Permittee*
Mark A. and Karen E. Kloefkorn
Applicant/Permittee Address*
105 Folly Creek Rd., Morrisville NC 27560
Facility Name *
105 Folly Creek Rd. SFR
Please provide comments/notes
on your current submittal below.
At this time, paper copies are no longer required. If you have any questions about what is required, please contact Nathaniel Thornburg
at [e-mail].
Please attach all information required or requested for this submittal to be reviewed here.*
(Application Form Engineering Rans, Spec'rfications, Calculations, Rc.)
Renewal.pdf 1.48MB
upload only 1 RCF docurrent (less than 250 NS). Ma@iple documents nest be corrbined into one RJF file unless file is larger than
upload limit.
* W By checking this box, I acknowledge that I understand the application will not be
accepted for pre -review until the fee (if required) has been received by the Non -
Discharge Branch. Application fees must be submitted by check or money order
and made payable to the North Carolina Department of Environmental Quality
(NCDEQ). 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).
Mail payment to:
NCDEQ — Division of Water Resources
Attn: Non -Discharge Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Signature
�� C) 6 t<�
Submission Date 2/12/2021

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.: WQ0021351
2. Permittee: Mark and Karen Kloefkom (i.e., deeded property owners)
3. Signature authority's name: Mark andKaren xloen orn (i.e., deeded property owner or legal representative) [15A NCAC 02T .0106(b)]
4. Physical address of residence with treatment/irrigation system: 105 Holly Creek Road
City: Morrisville State: NC Zip: 27560 _ County: Wake
5. Pemittee's mailing address (if different from above):
City: State: Zip: -
6. Permittee's contact information:
Primary Contact: Mark Kloefkorn Phone number: (919) 345 - 0935 Primary email address: Klocfkornmark(a)gmail.com
Secondary Contact: Mark Kloefkorn Phone number: (919 ) 345 - 0935 Secondary email address: [e-mail]
7. Has the treatment/inigation system been installed? A■ Yes or ❑ No
Applicant's Certification per 15A NCAC 02T .0106(b):
I, Mark Kloefkorn , 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: /off Lea e
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-Dischari4e.Reports@—ncdenr.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. WQ0021351 County: Wake B
Permittee: Mark and Karen Kloefkorn (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.
s
Signature: ✓1 Date: ad I
Signature: Date: 1,2em
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