WQ0022307_Application_20210607

Initial Review
Reviewer Thornburg, Nathaniel D
Is this submittal an application? (Excluding additional information.)*
r Yes r No
Permit Number (IR)* WQ0022307
Applicant/Permittee David A. Humphrey Sr.
Applicant/Permittee Address 1156 Horseshoe Trail
Is the owner in BIMS? r Yes r No Is the facility in BIMS? r Yes r No
Owner Type Individual
Facility Name Heritage Harbor Lot D SFR
County Person
Fee Category Single -Family Residence
Is this a complete
application?*
r Yes r No
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
Fee Amount $0
Complete App Date 06/07/2021
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 inforrafion on the person to be contacted by NDB Staff
Name * David Humphrey
Email Address*
[e-mail]
electronic subnittal, confirmation of receipt, and other correspondence.
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
Phone Number*
9738682690
O Modification - Minor
C Renewal
C GW-59, NDMR, NDMLR, NDAR-1,
NDAR-2
r Residual Annual Report
c 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:*
WQ0022307
Has Current Existing permt number
Applicant/Permittee *
David A. Humphrey Sr.
Applicant/Permittee Address*
1156 Horseshoe Trail
Facility Name *
Heritage Harbor Lot D SFR
Please provide comments/notes
on your current submittal below.
Heritage Harbor Lot D
Person County
Semora, NC 27343
Change of Ownership application
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, Spedications, Calculations, Bc.)
DWR_SewerWQ0022307_DHUMPHREY.pdf 1.32MB
t,load only 1 RDFdocument (less than 250 M3). Mafliple documents rust be corrbined into one RDFfile 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
Submission Date 6/6/2021

DoceSign Envelope ID: 89E1 D312-1924-44D9-9G27-8E8C74AC45F8
DWR
Division of W t R
State of North Carolina
Department of Environmental Quality
Division of Water Resources
a er esources 15A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE
WASTEWATER IRRIGATION SYSTEM — CHANGE OF OWNERSHIP
FORM: SFRWWIS-CO 03-21
Pursuant to 15A NCAC 02T .0107 b , 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 tin
NCAC 02T .0100, 15A NCAC 02T .0600, and Division Policies. For more information, visit the Water
Section's Non -Discharge Branch website. The Applicant shall submit an electronic copy of the application Quality
and attachments
uploaded as a single Portable Document Format (PDF) file to https: /edocs.de.nc. ov/Forms/NonDischar e-$ranch-Submittal-
For_ m-Ver2, or emailed to Non-Diis,cllarge.Rei)ortsC&aEgtnEln if less than 20 megabytes (MB).
SECTION I — APPLICANT INFORMATION
I. Applicant: David A. Humphrey, SR.
2, Permit No.: WQ0022307
3_ Signature authority: David A. Humphrey, SR.
4. Mailing address: / l
City:?
5. Contact pers_�
Primary phone number: 6133 �(� 1 4
6. Secondary Contact person. .1--pe -f
Primary phone number: 4119 9-$5 s lect
Title. Owner
State: 1?4 Zip: _,4Z-41jV
.� EmaiI. lvlko/ 35� '
&1Q�
e Secondary phone number: (5 Alect �_
Email: Vtf ,•�(4- W, ry
Secondary phone number: ( ) - Select
SECTION II— FACILITY INFORMATION
1. Physical address: Heritage Harbor Lot D
City: Semora
County: Person
State: NC
SECTION III — BILLING INFORMATION
Zip:27343-
1. ti1111ng address:
r
State: I
n Zip: `7 7
SECTION IV — DEED INFORMATION
Has a deed been executed and recorded in the County Register of Deeds pursuant to 15A NCAC 02T .0604 e ]
® Yes — Complete Items 1 through 4 below.
❑ No — See Attachment B on Page 3.
1. Parcel No.: 19816 & 9920
3. Deed Book: I046
2. Date of Purchase: August 11, 2020
4. Deed Page Nos.: 857 - 859
I
FORM: SFRWWIS-CO 03-21
Paae 1 of 3

DocuSign Envelope ID: 89EID312-1924-44D9-9C27-SE8C74AC45F8
SECTION V — OPERATION AND MAINTENANCE AGREEMENT ±
Permit No.: WQ0022307
Permittee: David A. Humphrey, SR. (i.e., all deeded property owners)
County: Person
The Permittee agrees to operate and maintain the single-family residence wastewater treatment and irrigation system as
follows:
I. 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. (ifapplicable)
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 Iines; 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. (f applicable)
S. 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 OwnershipaPplication 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.
Signature:
Signature:
the issued permit.
Date: 6 - % � I
Date:
Date:
Date:
All deeded Propertv owners shall si n this O eration and Maintenance Agreement
FORM: SFRWWIS-CO 03-2I
Page 2 of 3

DocuSign Envelope ID: 89E1 D312-1924-44D9-9C27-8E8C74AC45F8
ATTACHMENT A --- SIGNATURE AUTHORITY DELEGATION
Does the signature authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106 b
® Yes — 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 1)?
® Yes — Complete Items 1 through 4 in Section IV on Page 1.
❑ 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
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 .0120 , 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 .0106{b). An alternate person may be delegated as
the signing Official if a letter is provided pursuant to 15A NCAC 02T .0106 c . Pursuant to § 143-215.6A and § 143-215.6B, any
person wtPInowingly makes any faI a statement epresentat' n, or certification in any application package shall be guilty of a Class
s m
2 mieanor, hick may include/fine not t o ceed $1(0 as well as civil penalties up to $25,000 per violation.
Date: l2�9
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email: �Q �[1� "La.serfiche Upload:
Non-Dischar e.Re oris ncdenr. ov ht :/ledocs.de .nc. ov/Forms/No.nDischar e-Branch- -
Subm itta I -Form -Vert
FORM: SFRWWIS-CO 03-21
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