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Home My WebLink AboutWQ0040692_Application_20210330DWR State of North Carolina Department of Environmental Quality Division of Water Resources Division of Water Resources 15A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEM — CHANGE OF OWNERSHIP FORM: SFRWWIS-CO 03-21 Pursuant to 15A NCAC 02T .0107LbI, if the application does not include all required information and the necessary supporting documentation, the application shall be returned. The application and attachments shall be prepared in accordance with 15A NCAC 02T .0100, I5A NCAC 02T .0600, and Division policies. For more information, visit the Water Quality Permitting Section's Non -Discharge Branch website. The Applicant shall submit an electronic copy of the application and attachments uploaded as a single Portable Document Format (PDF) file to htt s://edoes.de .nc. ov/Forms/NonDischar e-Branch-Submittal- Form-Vert, or cmailed to Non-Dischar e.Re orts ncdenr. ov if less than 20 megabytes (MB). SECTION I — APPLICANT INFORMATION 1. Applicant: Brian Kent Janes and Beth Ann Janes 2. Permit No.: WQ0040692 3. Signature authority: t a �� C�VI�S �r Title: &Me_(3UMW,-_ 4. Mailing address: 1-7,A New Fto wv _ C LW_k._ City: �Ieu) i State: C_ Zip: X7� 5. Contact person: (3 a t_ �0. Ye e j Email: �,C iG�fi- j_ b- p @ QO(• CCAV% Primary phone number: (9ij)818-4gzC:�elect re(t Secondary phone number:( } - Select 6. Secondary Contact person: Email: �e`��;av s f�� S Awi •Cam► Primary phone number: (q { )Sa STSSelect cc-ij Secondary phone number: ( ) - Select SECTION 1I. — FACILITY INFORMATION 1. Physical address: 972 New Elam Church Road County: Chatham City: New Hill State: NC Zip: 27562- SECTION .III - BILLING INFORMATION 1. Billing addre ss: 017A Neal EjawtCixvG1-_ , City: N eu3 A 1(t State: G Zip: �L7,S&�, ;SECTION IV — DEED INFORMATION Has a deed been executed and recorded in the County Register of Deeds pursuant to 15A NCAC 02T _0604 e 1 ? ® Yes — Complete Items I through 4 below. ❑ No — See Attachment B on Page 3. 1. Parcel No.: 005792 2. Date of Purchase: February 10, 2021 3_ Deed Book: 02093 4. Deed Page Nos.: 1051 - 1052 FORM: SFRWWIS-CO 03-21 Pagel of 3 SECTION V - OPERATION AND MAINTENANCE AGREEMENT Permit No.: WQ0040692 County: Chatham Permittee: Brian Kent Janes and Beth Ann Janes (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. Me understand the above requirements and agree to these terms as part of the issued permit. Signature: ! Date: 3 —307,41_ x Signature: �" ' _ Date: �d y Signature: Date: Signature: Date: All deeded property owners shall sign this Operation and Maintenance Agreement FORM: SFRWWIS-CO 03-21 Page 2 of 3 ATTACHMENT A -- SIGNATURE AUTHORITY DELEGATION Does the signature authority in Section 1, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)? WfYes — Skip Attachment A. ❑ No — Submit a delegation letter pursuant to 15A NCAC 02T .0106(c) authorizing the signature authority to sign_ ATTACHMENT B —PROPERTY OWNERSHIP DOCUMENTATION Has a deed been executed and recorded in the County Register of Deeds pursuant to 15A NCAC 02T _0604(f)(1)? ® Yes — Complete Items 1 through 4 in Section IV on Page I. ❑ No ❑ Submit a written notarized intent to purchase agreement sign by both parties with a plat or survey map pursuant to 15A NCAC 02T .0604(e)(2); or ❑ Submit a 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 pursuant to 15A NCAC 02T .0604 e 3 . Lease agreements shall adhere to the requirements of 15A NCAC 02L .0107. APPLICANT'S CERTIFICATION I, t ` dd p, ^ z° attest that this application (Signature authority's name as noted in Section I, Item 3) 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 package are not completed, and that if all required supporting information and attachments are not included, this application package will be returned as incomplete. I further certify pursuant to 15A NCAC 02T .0 120, that the applicant, or any parent, subsidiary, or other affiliate of the applicant has: not been convicted of environmental crimes under; not previously abandoned a wastewater treatment facility without properly closing the facility; not paid a civil penalty; not been compliant with any compliance schedule in a permit, settlement agreement, or order; not paid an annual fee. Note: The Applicant's Certification shall be signed pursuant to 15A NCAC 02T .0I06(h). An alternate person may be delegated as the signing official if a letter is provided pursuant to 15A NCAC 02T .0106(e). Pursuant to § 143-215.6A and § 143-215.6B, 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: Date: 5 THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA: Email: Laserfiche Upload: (�1un I2ischar Re�eris nrd: nr.uov htt s://edoes.de .ne. oviForms/NonDischar e-Branch- Sulbmitta - old —rin=Vey---- FORM: SFRW WIS-CO 03-21 Page 3 of 3