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Home My WebLink AboutWQ0023185_Application_20210526DocuSlgn Envelope ID: 8681343D-318F-4AO7-8AOF-999EBC62CB20 State of North Carolina Department of Environmental Quality DWR Division of Water Resources NON -DISCHARGE PERMIT OWNERSHIP/NAME CHANGE Dh4sion of Water Resources INSTRUCTIONS FOR FORM: NDPONC 06-16 & SUPPORTING DOCUMENTATION This form is for ownership changes or name changes of a non -discharge system permit. Please note that "Permtttee" references the existing permit holder, and that "Applicant" references the entity applying for the ownership/name change. For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit website A. Non -Discharge Permit Ownership/Name Change (FORM: NDPONC 06-16) Application (All Applications): ® Submit an original completed and appropriately executed Non -Discharge Permit Ownership/Name Change (FORM: NDPONC 06-16) application. ® The Existing Permittee's Certification shall be signed in accordance with 15A NCAC 02T .0106(b). Per 15A NCAC 02T .0106 c an alternate person may be designated as the signing official if a delegation letter is provided from a person who meets the criteria in 15A NCAC 02T .0106(b). ® The Applicant's Certification shall be signed in accordance with 15A NCAC 02T .0106(b). Per 15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from a person who meets the criteria in 15A NCAC 02T .0106(b). B. Existing Permit (All Applications): ® Submit a copy of the most recently issued permit. C. Property Ownership Documentation (All Applications): ➢ Per 15A NCAC 02T .0504(f), 15A NCAC 02T .0604(e), 15A NCAC 02T .0704(f), 15A NCAC 02T .0804, 15A NCAC 02T .1004(d), 15A NCAC 02T. I 104(d)(7), 15A NCAC 02T. 1 104(c)(5), 15A NCAC 02U .0201(e} or 15A NCAC 02U .0202(f) the Applicant shall demonstrate they are the owner of all property containing the non -discharge system facilities: ® Legal documentation of ownership (i.e., GIS, 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 NCAC 02L .0107. D. Certificate of Public Convenience and Necessity (All Applications where the Applicant is a Privately -Owned Public Utility): ❑ Per 15A NCAC 02T .0115(a)(1), provide one copy of the Certificate of Public Convenience and Necessity from the North Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the non -discharge system. E. Operational Agreements (All Applications where the Applicant is a Home/Property Owners' Association or Developer of lots to be sold): ➢ Home/Property Owners' Associations ❑ Per 15A NCAC 02T .0115(c), submit an original properly executed Operational Agreement (FORM: HOA). ❑ Per 15A NCAC 02T .0115(c), submit an original proposed or approved Articles of Incorporation, Declarations and By- laws. ➢ Developers of lots to be sold ❑ Per 15A NCAC 02T .0115(b), submit an original of the properly executed Operational Agreement (FORM: DEV). F. Operation and Maintenance Agreement (All Applications for Singlc-Family Wastewater Irrigation Systems): ® Per 15A NCAC 02T .0604 . submit an original of a notarized Operation and Maintenance Agreement (FORM: SFRWWIS O&M) that has been signed and dated by all deeded property owners. THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED TO: NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY DIVISION OF WATER RESOURCES WATER QUALITY PERMITTING SECTION NON -DISCHARGE PERMITTING UNIT By U.S. Postal Service: By Courier/Special Delivery: 1617 MAIL SERVICE CENTER 512 N. SALISBURY ST. RALEIGH, NORTH CAROLINA 27699-1617 RALEIGH, NORTH CAROLINA 27604 TELEPHONE NUMBER: (919) 807-6464 FAX NUMBER: (919) 807-6496 INSTRUCTIONS FOR FORM: NDPONC 06-16 & SUPPORTING DOCUMENTATION Page 1 of 1 DocuSign Envelope ID: 8681343D-318F-4AO7-8AOF-999EBCB2CB20 State of North Carolina Department of Environmental Quality Division of Water Resources NON -DISCHARGE PERMIT OWNERSHIP/NAME CHANGE Division of Water Resources FORM: NDPONC 06-16 I. EXISTING PERMITTEE INFORMATION: 1. Permittee's name: Dan Schwahn and Cynthia Schwalm 2. Signature authority's name: owner/seller per 15A NCAC 02T .0106 b Title: 3. Permittee's mailing address: 505 Clyde4jah�l Rd City: Apex State: NC Zip: 2, �j23 4. Permittee's contact information: Phone number: (919) 441-2808 Email Address: cschwalm2{a]outlook.com 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 environmental crimes under Federal law or G.S. 143-215.613? ❑ Yes or ® No b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or ® 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 15A NCAC 02T .0105(e)(2)? ❑ Yes or ® No U. FACILITY INFORMATION: 1. Facility name: Septic system on private land 2. Facility's physical address: 505 Clyde Farrell RdZi523 City: Apex State: NC Zip: County: Chatham III. PERMIT INFORMATION: 1. Existing permit number: WQ0023185 and most recent issuance date: June 12, 2008 2. Existing permit type: Single -Family Residence Wastewater Irrigation 3. Reason for the permit application: Change of Ownership 4. Has the facility been constructed? ® Yes or ❑ No IV. APPLICANT INFORMATION:^. 1. Applicant's name: Edward & T-e>:iea Ernst t'E 2. Signature authority's name: buyer/new owner per 15A NCAC 02T .0106(b) Title: 3. Applicant's mailing address: 505 Clyde Rd � 2 City: Apex State: NC Zip:36-S2-3- 4. Applicant's contact information: Phone number: (l`-[fig] Email Address:wat.rc(� Ling f j,yV.;1.cft, 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 environmental crimes under Federal law or G.S. 143-215.6B? ❑ Yes or ® No b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or ® 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 15A NCAC 02T .0105(e)(2)? ❑ Yes or ® No FORM: NDPONC 06-16 Pagel of 2 DocuSign Envelope ID: 8681343D-318F-4AO7-8AOF-999EBC62CB20 Existing Permittee's Certification per 15A NCAC 02T .0106(b): Daniel J Schwalm Cynthia L. Schwalm (Signature Authority's name & title from Application Item 1.2.) (Facility nalne from Application Item II.1.) attest that this application for 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 are not included, this application package will be returned as incomplete. I further certify that the existing Permittee 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(e]. 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 be guilty of a Class 2 misdemeanor, which may include a fine not to exceed $10,000oa u n 1, jj civil penalties up to $25d00��(�11i��ea by:�� Signature: �I �' J SGUAN N1A I,U WA�N1 Date: 4/29/2021 1 12 : 32 PM PDT g 6C563C46BF3C4E1... 69661 CABA1 RB8... Applicant's Certification per 15A NCAC 02T .0106(b): I, COI r-1, 1 S-7 t e ri. EL attest that this application for (Signature Authority's name & title from Application Item IV.2.) G TrL T O c_ S -- I ~3-7e.,,r, W, ?e—i 1f11A`--T -- t (Facility name from Application Item II.1.) has been reviewed by me 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(e). 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 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: FORM: NDPONC 06-16 Page 2 of 2 State of North Carolina Department of Environment and Natural Resources Division of Water Resources DWR 15A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEMS OPERATION AND MAINTENANCE AGREEMENT Division of Water Resources FORM: SFRWWIS O&M 08-13 Permit No. 2-3 1'c&_S County: Property owner(s) as appearing on the recorded deed: Mailing address: S E"J I_ +=- 1 ( IZai , A—r-"s-A, i\J G 2-7523 Facility address: S-OS GI fie. 2--75 z3 Irrigation Method: O-SPRAY ❑ DRIP I / We agree to operate and maintain the single-family residence wastewater treatment and irrigation system as follows: 1. The Permittee is responsible for the operation and maintenance of the entire wastewater treatment and irrigation system including, but not limited to, the following items: a. The septic tank shall be checked annually and pumped out as needed. b. The septic tank effluent filter shall be checked and cleaned annually. c. Accessible sand filter surfaces shall be raked and leveled every six months and any vegetative growth shall be removed manually. d. e tablet chlorinator shall be checked weekly. Wastewater grade tablets (calcium hypochlorite) shall be added as needed to provide proper chlorination (pool chlorine tablets shall not be used), OR ❑ The ultraviolet disinfection unit shall be checked weekly. The lamp(s) and quartz sleeve(s) shall be cleaned or replaced as needed to ensure proper disinfection. e. All pump and alarm systems shall be inspected monthly. f. The irrigation system shall be inspected monthly to ensure that the system is free of leaks, that all irrigation equipment is operating as designed, that vegetative growth does not interfere with the system inspection or operation, that the soil is assimilating the disposed treated wastewater with no visible runoff or ponding, and that no objectionable odors are being generated. 2. Failure to pay the annual fee shall be cause for the Division to revoke the permit pursuant to 15A NCAC 02T .0105(e)(3). 3. The Permittee's failure to properly operate this system is subject to a penalty up to $25,000 per day. 4. Failure to meet the permit conditions or violation of the State's surface water or groundwater regulations may void the permit. All owners appearing on the legally recorded propertv deed shall sign this Operation & Maintenance Agreement I / We understand the above requirements and agree to these terms as part of the issued permit. Owner Signature: C� �� _ Date Owner Signature: Date s1zi1zi 5 21 121 FORM: SFRWWIS O&M 08-13 Page 1 of 1 IN WITNESS WHEREOF, Grantors have hereunto set their hands and seals all as of the day and year first above written. _ _. (SEAL) EDWARD LLOYD ERNST STATE OF �/ ('Ill COUNTY OF Lk44,vk I, a Notary Public of W. �& County and State aforesaid, certify that the following person(s) personally appeared before me this day, each acknowledging that he or she voluntarily signed the foregoing document for the purpose stated therein and in the capacity indicated: EDWARD LLOYD ERNST 4"d �'-4y- Printed Name of Notary: Notary Public �! J My commission expires: TERIKA LYNE SPENCER t CA 5 (SEAL) STATE OF AIL - COUNTY OF L 4r- 4;; I, a Notary Public of Wo Il' County and State aforesaid, certify that the following person(s) personally appeared before me this day, each acknowledging that he or she voluntarily signed the foregoing document for the purpose stated therein and in the capacity indicated: TERIKA LYNE SPENCER �-IA $ t Date: ♦� k yb, y • �+alllla�� Printed Nam eof %wl Notary Public My commission expires: ,_