WQ0021050_Application_20210302

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.: WQOO�L rj
2. Permittee: �,Il` { P �S 0" (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 treatm�ntliltion system: Oc) i�orapSS LZI �I
City: State: NC Zip:,4,3;R- County: Select _fham
5. Pemittee's mailing address (if different from above):
City:
State: Zip:
6. Permittee's contact information:
Primary Contact: �2 L �7'•,_i" Phone number: I la[�� Primary emai l address: "
-�� - - � - �`�L) ...__- _ -� r� tel:
Secondary Contact: 6011nkL ` Phone number.}- ��� Secondary entail address:
r_�sa��
7. Has the treatment/irrigation system been installed? (.P'Yes or ❑ No
Applicant's Certification per 15A NCAC 02T .0106(b):
1, 0(-)&- 6l:pp s L-r. attest that this renewal application has been reviewed by me, and is
accurate and complete to he best of mylm6wledge. 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.
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-Qischarge.Reports0=denr.gnv
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
Division of Water Resources
Permit No. WQ00C�( I () j Q
Permittee:
Department of Environmental Quality
Division of Water Resources
SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEM
OPERATION AND MAINTENANCE AGREEMENT
FORM: SFRWWIS-O&M 09-18
County: Select
(i.e., all deeded property owners)
The Permittee-igrees to operate and maintain the singli-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.
4
V
Signature: Date: 3 —,�2
Signature: Date:
Signature:
Signature:
Date:
Date:
All deeded ormertv owners shalt si n this Operation and Maintenance „Aereement
FORM: SFRWWIS-O&M 09-18 Page 1 of 1