WQ0033896_Application_20210915

LM
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Dlvlslon of Water Resources 15A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE
WASTEWATER IRRIGATION SYSTEM — RENEWAL
FORM: SFRWWIS-R 02-21
Pursuant to 15A NCAC 02T .0107 b , if the application does not include ail 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, 15A 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 https://edocs.deg.nc.gov/Forms/NonDischarge-
Branch-Submittal-Form-Vert, or emailed to Non-Discharge.Reports(&ncdenr.sov if less than 20 megabytes (MB).
_ s
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1.
Applicant: Z 6 u_SS
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2.
Permit No.: WQ00
3.
Signature authority: { �,
Title:
4.
Mailing address:
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City: pr Cl. Ze !J / C r 1
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State: Zip
5.
Contact person: i t �jF[�t
Email: Q F li S S £r/ (q p r/
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Secondary phone number:
Primary phone number:(
6.
Secondary Contact person::: An,��°` 0- Fl>s t
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Email: 641�'e, -t�SSc
phone
Primary phone number: ( �/ Select
Secondary number: ( ) - Select
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1. Physical address:
County:
City:.. _5 /r�
�(i l�Y� St �_t4-U
State: NC N' C:'
Zip:
a IL
1. Billing address:
City: State: f v r Zip: v�S
2. Verify the Applicant does not have any overdue annual fees:
htt s://de .ne. ov/about/divisions/water-resources/water-resources- ermits/w -e a ments
Pursuant to 15A NCAC 02T A 120(c), permits for renewing facilities shall not be granted if the Applicant or any affiliation has
an unpaid annual fee.
FORM: SFRWWIS-R 02-21 Page i of 4

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)
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 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.
IIWe understand the above requirements and agree to these terms as part of the issued permit.
Signature:,�t� B� Date:
Signature:
Signature:
Signature:
Date:
Date:
Date:
All deeded property owners shall sijZn this Operation and Maintenance Agreement
FORM: SFRWWIS-R 02-21 Page 2 of

J
Was the facility originally permitted or had a major modification issued after September 1, 2006?
M Yes — Pursuant to 15A NCAC 02`i .0105 d , submit a site map pursuant to the requirements in 15A NCAC 02T .0604(d).
These requirements are:
❑ A scaled map of the site with topographic contour intervals not exceeding 10 feet or 25 percent of total site relief and
showing all facility -related structures and fences within the wastewater treatment, storage, and irrigation areas.
❑ Soil mapping units shown on all irrigation sites.
❑ The location of all wells (including usage and construction details if available), streams (ephemeral, intermittent, and
perennial), springs, lakes, ponds, and other surface drainage features within 500 feet of all wastewater treatment, storage,
and irrigation sites.
❑ Delineation of the compliance and review boundaries per 15A NCAC 02L .0107 and .0108, and 15A NCAC 02T .0601.
❑ Setbacks as required by 15A NCAC 02T .0606.
❑ Site property boundaries within 500 feet of all wastewater treatment, storage, and irrigation sites.
❑ All habitable residences or places of public assembly within 500 feet of all treatment, storage, and irrigation sites.
❑❑ No — Skip Attachment A.
Does the signature authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)? ❑
On Yes — Skip Attachment B.
❑ No — Submit a delegation letter pursuant to 15A NCAC 021.0106 c authorizing the signature authority to sign.
Does the existing permit include an approved flow reduction?
❑❑ Yes — Submit a copy of the flow reduction approval letter, as well as the measured monthly average amount of wastewater
flow contributed per unit for the 12 months prior to permit renewal. if any of these monthly averages are within 20% of the
approved flow reduction value, the Permittee shall provide a reevaluation of the reduced flow value pursuant to the
requirements in 15A NCAC 02T .0114(f).
No — Skip Attachment C.
Does the Permittee own all of the land associated with the wastewater collection, treatment, conveyance, and irrigation system?
NIX Yes — Skip Attachment D.
❑❑ No — Pursuant to 15A NCAC 02T .0116 c , provide a copy of all easements, lease agreements, and encroachment
agreements allowing the Permittee to operate and maintain the wastewater collection, treatment, conveyance, and irrigation
system on property not owned by the Permittee.
1
Are the Permittee's affiliations of record correct? Check affiliations.
M Yes — Skip Attachment E.
❑❑ No — Provide the corrected affiliations and their contact information.
Does the existing permit include any Compliance Schedules? (See Section I of the most recently issued permit)
❑❑ Yes — Submit documentation that the compliance schedules have been met.
©❑ No — Skip Attachment F.
FORM: SFRWWIS-R 02-21 Page 3 of 4

Does the Permittee have any existing civil penalties or outstanding violations?
❑❑ Yes (civil penalties) — Submit payment for the civil penalty, or proof of remission request.
❑❑ Yes (violations) — Submit a copy of your response to the Notice of Violation,
®® No — Skip Attachment G.
Does the existing permit include setback waivers?
©❑ Yes — Pursuant to 15A NCAC 02T .0606(c), provide setbacks waivers that have been written, notarized, signed by all parties
involved, and recorded with the county Register of Deeds. Waivers involving the compliance boundary shall be in accordance
with 15A NCAC 02L .0107.
❑❑ No — Skip Attachment H.
1 Z t-) belk 11 cone USS I attest that this applicatio
(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(b), 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 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: - Ui—/ Date: /
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email: Laserf;che Upload:
Non-Dischar2e.ReportsOncdenr.gov https Hedocs.deg.ne.gov/Forms/NanDischarge-Branch-
Submittal-Form-Ver2
FORM: SFRW WIS-R 02-21 Page 4 of 4

8 "M
AOL
The clear leader.
AQWA Inc.
2604 Willis Court, Wilson, NC 27896
Phone: [phone] - Email: [e-mail]
Customer Name: Fussell
Date of inspection:
712D12021
Address: Fussell - 557 Belt Road Hampstead, NC 28443
System AX ID:
AX-121965
Permit No.
County:
DWQ-Wilm
Arrival Time 02:05 PM
Departure Time
03:36 PM
Inspectior and
or • Surface
or Dhp
Dispersal
Seploq TialVittp)
Tank At Site Tank 1
Tank 1 Inlet Readings
Tank 2 Inlet Readings
1 Scum 12
Sludge
Scum
Sludge
Tank 1 Outlet Readings
Tank 2 Outlet Readings
0 Scum 12
Sludge
Scum
Sludge
Clean Effluent Filter: Cleaned
Check for Influent or Effluent Blockages: Cannot see inlet pipe
Inspect TankfRiser for Leaks: None Seen
Col" PwoM kopedion
Check Pump Operates In Manual Mode: Yes
Reoircular Pumps Recirculation Pump 1
Pump 1 Timer Settings
Pump 2 Timer Settings
DA Dose 19.6
Rest
Dose
Rest
Pump 1 - Counters and Elapsed Time Meters
Pump 2 - Counters and Elapsed Time Meters
80439 CT 134.2
ETM
CT
ETM
Verify Conduit Seal: Verified
AM ' MMUMiK POW$) 1111,110POC111611M'
AX Treatment Pod(S)
Pot
Inspect for Ponding or Bridging:
None
Check and Record Squirt Height:
3 it
Verify Orifice Position and Assess for Clogging:
Cleaned
Check for Odors:
None
Clean, Brush, Flush Lateral:
Done
Recheck and Record Squirt Height:
3 it
Flush Pod Throroughly:
Done
Inspect and Clean Vents:
Cleaned

Inspection and Maintenance Checklist
- 1 . . Surface or Surface Drip
Dispersal
R�eclrse��lEton 7°arttk Msp4c#Ion
Verify Inlet Flow: No Inflow
Inspect Liquid: Normal Level
Record Scum/Sludge Levels:
Inlet Readings:
Outlet Readings:
0 Scum 8 Sludge
0 Scum 8
Sludge
Inspect Tanl iser for Leakage: None Seen
Verify All Floats Work:
Operating Properly
Visually Check RSV and Liquid Leval Normal
Verify Audible Alarm Works for High Water float:
Works Properly
Clean BiotubelPump Vault Filter Cartridge: Cleaned
Verify Neat Wrap of Float and Pump Cords:
Checked
Inspect BiotubelPump Vault Filter Cartridge: Ok
Verify Conduit Seal:
Verified
Pull Pump and Clean Screen: Not Necessary
Verify No Leaking In Piping or Flex Hoses:
None Seen
UUmvloW Dlskifectlon Unit ktsptllr:Hon
Does System Have a UV? No
How Many UV Disinfectant Units Present?
After Disconnecting Power, Clean or Replace Bulb As Needed:
Flush Housing Thoroughly:
Return Power and Verify Proper Function:
FkWW Dosing Tank Inipoction
Inspect for Tank/Riser Leakage: None Seen
Inspect Liquid: Normal Level
Record Scum/Sludge Levels:
Inlet Readings:
Outlet Readings:
Scum Sludge
0 Scum 2
Sludge
Visually Check Liquid Level: Normal
Verify Audible Alarm Works for High Water float:
Works Properly
Verify No Leaks In Piping or Flex Hoses: None Seen
Verify Neat Wrap of Float and Pump Cords:
Verified
Inspect Pump Intake: Ok
Delivery Rate at Start Up:
6.3
Verify All Floats Work: Operating Property
Verify Conduit Seal:
Verified
Drip Irrii System MapeWon
Areas Mowed and Clear of Obstruction: Yes
Area Free of Ponding or Surface Effluent: Yes
Curtain Drains, Ditches, Swales Functioning Properly: Yes
Control Panel Communication Checked: Panel has dial tone but did not call in while on site. Called In 7113121.
Ins ticrn fttss
Chlorine tablets in dispenser
Chad Allen
Operator
Operators Signature

15 AQWA�
ihedearleader. AQWA Inc.
2604 Willis Court, Wilson, NC 27896
Phone: [phone] - Email: [e-mail]
Customer Name: Fussell System:
Inspector: Chris Taylor Date of Inspection:
Departure Time:
Current
Flow Meter: 813410
Previous Inspection Re
Flow Meter: 798160
Elapsed Calculations
Total Flow Since Last Visit:
Spin Filter: Cleaned
Zone Testing
so
3.2021
Date of Previous inspection:
2/1112021
80
15250 Number of Days: so Average Daily Flow: 19o.eZ5
Filtrate Return Line: No
Inspection Comments
:? leaks in zone 1. No other leaks seen when walking the field

A, WA
The clear leader
AQWA Inc.
2604 Willis Court, Wilson, NC 27896
Phone: [phone] — Email: [e-mail]
Customer Name: Fussell Date of Inspection: 513/2021
Address Fussell - 557 Belt Road Hampstead, NC 26443 System AX lU AX-121965
Permit No. County: DWO-wiim
Arrival Time Departure Time
SurfaceInspection and Maintenance Checklist - AX20 (1, 2, or 3) Sub or Surface Drip Dispersal
Septic Tank Inspection
Tank At Site Tank 1
Tank 1 Inlet Readings Tank 2 Inlet Readings
i Scum 12 Sludge Scum Sludge
I
Tank 1 Outlet Readings Tank 2 Outlet Readings
0 Scum 14 Sludge Scum Sludge
ranklnspecNon.
Clean Effluent Filter: Cleaned
Check for Influent or Effluent Blockages. No Blockage
Inspect Tank/Riser for Leaks: None Seen
Control Panel Inspection
Cneck Pump Operates In Manual Mode, Yes
Recircular Pumps Recirculation Pump 1
Pump 1 Timer Settings Pump 2 Timer Settings
0.4 Dose 19.5 Rest Dose Rest
Pump 1 - Counters and Elapsed Time Meters Pump 2 - Counters and Elapsed Time Meters
75045 CT 97.2 ETM CT ETM
Verify Conduit Seal: Verified
AX20 Treatment Pod(s) Inspection
jAx Treatment Pod(S) P01
r
Pod inspecWn f,�.''.':? . ,:: `{.. -: $ . , a - „#, ,, ,,. .. '..'fit. ir..:ipl a - '-' � - c,kiGs� 1,.-. -
.',_ . . �.:' , �. x,•, «. Pod 4
Inspect for Ponding or Bridging: None
I
i Check and Record Squirt Height: 3 ft
E
Verify Orifice Position and Assess for Ciogging: Ok
i
Check for Odors: None
Clean, Brush, Flush Lateral: Done
Recheck and Record Squirt Height. 3 ft
Flush Pod Throroughly. Done
inspect and Clean Vents Vents Clear
i I

0 ACLWA
The clear leader
AQWA Inc.
2604 Willis Court, Wilson, NC 27896
Phone: [phone]
-- Email: [e-mail]
Customer Nam- Fussell
systern: SD
r Chad Alm
Data of Inspection: July 20, 2021
Anlvall Time:
Departure Time:
Drip Irrigation
Cunwit Readings
Zone Flush Zone I Zone 2 Zone 3 Zone 4
Pump
Counter 2430
Filter Flush
223: 363 4t56
Timer 105.1
2.8 3.6 40468 38975
Flow Meter: 828800
Previous irrspet sort Readings
Date of Previous Inspection: 50=1
81 9AQ 40" 361+t
81.4
2.2 2.8 1 39782 38288
Flow Meter: 813410
Itpeed Cahmiadons
Elapsed Days: 78
13T
142 73f 66 .' . .
23.7
0.6 0.8 686 687
Total Flow Since Last Visit:
15390 Number of Days: 78 Average Daily Flow: 197.3076923
Spin Filter: Replaced
Filtrate Return Line: No
Zone Testing
Zone 3
Zone 4
Zone 1
Pre Filler {PSI} Post Filter (PSI)
Bose Rate (GPM)_
Supply PSI
Return PSI
Zone 2
.-
.�
Flush Rate GPM
Flush Supply PSI
Flush R ,tun" PSI r
inspec#on Comments
Fixed a blow out in zone 1. Replaced spin filter and housing. Couldn't get

it to stop leaking.
Inspector's Signature

I.
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
RALEIGH
SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEM PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules and Regulations
PERMISSION IS HEREBY GRANTED TO
Elizabeth B. Fussell
Pender County
FOR THE
continued operation of a 480 gallon per day (GPD) single-family residence wastewater treatment and
irrigation facility consisting of:
a 1,500 gallon precast concrete baffled septic tank with an effluent filter; a 1,700 gallon precast concrete
baffled recirculation tank with a 10 gallon per minute (GPM) recirculation pump, audible/visual high water
alarms, and a recirculating splitter valve; an Advantex ® AX20 textile -based filtration pod with a filter
surface area of 20 square feet (ft'); a tablet chlorinator; a 4,900 gallon storage tank providing five days of
effective storage time with a 10 GPM irrigation pump, and a rainfall sensor; a 0.13 acre drip irrigation area;
and all associated piping, valves, controls, and appurtenances
to serve the single-family residence at 557 Belt Rd., Hampstead, NC 28443, with no discharge of wastes to
surface waters, pursuant to the application received January 23, 2017, and in conformity with the project
plans, specifications, and other supporting data subsequently filed and approved by the Department of
Environmental Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until December 31, 2021, shall void Permit No.
WQ0033896 issued September 18, 2009, and shall be subject to the following specified conditions and
limitations:
1. No later than six months prior to the expiration of this permit, the Permittee shall request renewal of
this permit on official Division forms. Upon receipt of the request, the Division will review the
adequacy of the facilities described therein, and if warranted, will renew the permit for such period of
time and under such conditions and limitations as it may deem appropriate. Please note Rule 15A
NCAC 02T .0105(d) requires an updated site map to be submitted with the permit renewal application.
[15A NCAC 02T .0105, 02T .0109, 02T .0115(c)]
2. If a public or community sewage system is or becomes available, the subject single-family residence
wastewater treatment and irrigation facilities shall be closed and all wastewater shall be discharged into
the public or community sewage system within 180 days of its availability. Prior to the initiation of
these connection activities, appropriate Division approval shall be received. [15A NCAC 02T .0607]
WQ0033896 Version 2.0 Shell Version 151201 Page 1 of 6

II. PERFORMANCE STANDARDS
The subject non -discharge facilities shall be effectively maintained and operated at all times so there is
no discharge to surface waters, nor any contravention of groundwater or surface water standards. In
the event the facilities fail to perform satisfactorily, including the creation of nuisance conditions due
to improper operation and maintenance, or failure of the irrigation areas to adequately assimilate the
effluent, the Permittee shall take immediate corrective actions including Division required actions, such
as the construction of additional or replacement wastewater treatment or disposal facilities. [15A
NCAC 02T .0108(b)(1)]
2. This permit shall not relieve the Permittee of their responsibility for damages to groundwater or surface
water resulting from the operation of this facility. f 15A NCAC 02B .0200, 02L A 100]
3. Application rates, whether hydraulic, nutrient or other pollutant, shall not exceed those specified in the
following table:
TABLE 1 — APPLICATION LIMITATIONS
Field
Parameter
Hourly Rate
Yearly Max
Units
1
01284 — Non -Discharge Application Rate
0.12
49.61
inches
[15A NCAC 02T .06050)]
4. The subject facility has been approved to land apply wastewater effluent on the following fields:
TABLE 2 — IRRIGATION AREA INFORMATION
Field
Owner
County
Latitude
Longitude
Net
Dominant
Acreage
Soil Series
1
Elizabeth B. Fussell
Pender
34.4570230
-77.5557320
0.13
Ra—Rains fine
sandy loam
[G.S. 143-215.1 ]
5. The Operation and Maintenance Agreement (attached) between the Permittee and the Division of Water
Resources is incorporated herein by reference and shall be a condition of this permit. Noncompliance
with the terms of the Operation and Maintenance Agreement shall subject the Permittee to all sanctions
provided by North Carolina General Statutes § 143-215.6A to § 143-215.6C for violation of or failure
to act in accordance with the terms and conditions of this permit. [15A NCAC 02T .0115 (2)]
6. The irrigation system shall be connected to a rain or moisture sensor, which shall indicate when effluent
application is not appropriate in accordance with Conditions 1II.4. and III.5. of this permit. [15A NCAC
02T .0605(o)]
7. The compliance boundary is established at the property boundary. Any exceedance of standards at the
compliance boundary shall require action in accordance with 15A NCAC 02L .0106. [15A NCAC 02L
.0107(i)]
8. The review boundary is established midway between the compliance boundary and the effluent disposal
area. Any exceedance of groundwater standards at the review boundary shall require action in
accordance with 15A NCAC 02L .0106. [15A NCAC 02L .0108]
9. The Permittee shall apply for a permit modification to establish a new compliance boundary prior to
any sale or transfer of property affecting a compliance boundary. [15A NCAC 02L .0107(c)]
WQ0033896 Version 2.0 Shell Version 151201 Page 2 of 6

10. The facilities permitted herein shall be constructed according to the following setbacks:
a. The setbacks for irrigation sites permitted under 15A NCAC 02T .0600 shall be as follows (all
distances in feet):
i. Any habitable residence or place of public assembly under separate ownership: 100
ii. Any habitable residence or place of public assembly owned by the Permittee:
15
iii. Any private or public water supply source:
100
iv. Surface waters:
100
v. Groundwater lowering ditches:
100
vi. Surface water diversions:
25
vii. Any well with exception of monitoring wells:
100
viii. Any property line:
501
ix. Top of slope of embankments or cuts of two feet or more in vertical height:
15
x. Any water line from a disposal system:
10
xi. Subsurface groundwater lowering drainage systems:
100
xii. Any swimming pool:
l00
xiii. Public right of way:
50
xiv. Nitrification field:
20
xv. Any building foundation or basement:
15
k Per a setback waiver recorded in the Pender County Register of Deeds, setbacks
from the
wetted area to any property line has been reduced for the following:
PIN
Deed Book I Page
Setback
Easement
4236-50-1773-0000
3709 / 0123
39 feet
I 1 feet
[15A NCAC 02T .0606(a)]
b. The setbacks for storage and treatment units permitted under 15A NCAC 02T .0600 shall be as
follows (all distances in feet):
i. Any habitable residence or place of public assembly under separate ownership:
ii. Any private or public water supply source:
iii. Surface waters:
iv. Any well with exception of monitoring wells:
v. Any property line:
100
100
50
100
50'
' Per a setback waiver recorded in the Pender County Register of Deeds, setbacks from the
storage and treatment units to any property line has been reduced for the following:
PIN
Deed Book / Page
Setback
Easement
4236-50-1773-0000
3709 / 0123
10 feet
40 feet
[15A NCAC 02T .0606(b)]
M. OPERATION AND MAINTENANCE REQUIREMENTS
1. The facilities shall be properly maintained and operated at all times. The facilities shall be effectively
maintained and operated as a non -discharge system to prevent the discharge of any wastewater resulting
from the operation of this facility. The Permittee shall maintain an Operation and Maintenance Plan
pursuant to 15A NCAC 02T .0604(f). [ 15A NCAC 02T ,0604(f)]
WQ0033896 Version 2.0 Shell Version 151201 Page 3 of 6

2. Upon the Water Pollution Control System Operators Certification Commission's (WPCSOCC)
classification of the subject non -discharge facilities, in accordance with 15A NCAC 08G .0200 the
Permittee shall designate and employ a certified operator in responsible charge (ORC) and one or more
certified operator(s) as back-up ORC(s). The ORC or their back-up shall visit the facilities in
accordance with 15A NCAC 08G .0200, and shall comply with all other conditions specified in the
previously cited rules. [15A NCAC 02T .0117]
3. A suitable year round vegetative cover shall be maintained at all times, such that crop health is
optimized, allows for even distribution of effluent and allows inspection of the irrigation system. [15A
NCAC 02T .0108(b)(1)]
4. Adequate measures shall be taken to prevent effluent ponding in or runoff from the irrigation sites listed
in Condition IIA. [15A NCAC 02T .0605(o)]
5. Irrigation shall not be performed during inclement weather or when the ground is in a condition that
will cause ponding or runoff. [15A NCAC 02T .0605(o)]
6. Only effluent from the single-family residence at 557 Belt Rd., Hampstead, NC 28443 shall be irrigated
on the sites listed in Condition 11.4. [G.S. 143-215.1 ]
7. No automobiles or machinery shall be allowed on the irrigation sites except during equipment
installation or while maintenance is being performed. [15A NCAC 02T .0108(b)(1)]
8. Public access to the irrigation sites and wastewater treatment facilities shall be prohibited. Fencing
shall be provided to prevent access to the irrigation site (minimum 2-strand wire) and treatment units
shall be secured with locks on all tank accesses and control panels. [15A NCAC 02T .0605(i)]
9. The residuals generated from the wastewater treatment facilities shall be disposed or utilized in
accordance with 15A NCAC 02T .1100. [15A NCAC 02T .1100].
10. Diversion or bypassing of untreated or partially treated wastewater from the treatment facilities is
prohibited. [ 15A NCAC 02T .0605(f)]
11. Pump/dosing tanks shall have audible and visual alarms external to any structure. [15A NCAC 02T
.0605(n)]
12. The Permittee is responsible for the operation and maintenance of the entire treatment and disposal
system including, but not limited to, the following items:
a. The septic tank shall be checked annually and pumped out as needed. The septic tank effluent filter
shall be checked and cleaned at the same frequency as the septic tank. [15A NCAC 18A .1900,
02T .0605]
b. The tablet chlorinator shall be checked weekly. Wastewater grade chlorine tablets (calcium
hypochlorite) shall be added as needed to provide proper chlorination. Pool chlorine tablets shall
not be used. [15A NCAC 02T .0605(1)]
c. The storage, pump, and alarm systems shall be inspected monthly. The scum layer in the pump
tanks shall be removed at the same interval as the septic tank is cleaned out. [15A NCAC 02T
.0108(b)(1)]
d. The system shall be inspected monthly to make certain of the proper operation of the drip lines,
that the system is free of leaks, that the vegetative growth allows a proper drip pattern, that the soil
is assimilating the disposed treated wastewater with no surface runoff, and that no objectionable
odors are being generated. [ 15A NCAC 02T .0108(b)(1)]
WQ0033896 Version 2.0 Shell Version 151201 Page 4 of 6

IV. MONITORING AND REPORTING RE UIREMENTS
1. Any Division required monitoring (including groundwater, plant tissue, soil and surface water analyses)
necessary to ensure groundwater and surface water protection shall be established, and an acceptable
sampling reporting schedule shall be followed. [15A NCAC 02T .0108(c)]
2. Noncompliance Notification:
The Permittee shall report by telephone to the Wilmington Regional Office, telephone number (910)
796-7215, as soon as possible, but in no case more than 24 hours, or on the next working day following
the occurrence or first knowledge of the occurrence of any of the following:
a. Any process unit failure (e.g., mechanical, electrical, etc.), due to known or unknown reasons,
rendering the facility incapable of adequate wastewater treatment.
b. Any facility failure resulting in a by-pass directly to receiving surface waters.
c. Any time self -monitoring indicates the facility has gone out of compliance with its permit
limitations.
d. Ponding in or runoff from the irrigation sites.
Any emergency requiring immediate reporting (e.g., discharges to surface waters, imminent failure of
a storage structure, etc.) outside normal business hours shall be reported to the Division's Emergency
Response personnel at telephone number [phone], [phone], or [phone]. Persons
reporting such occurrences by telephone shall also file a written report in letter form within five days
following first knowledge of the occurrence. This report shall outline the actions taken or proposed to
be taken to ensure the problem does not recur. [15A NCAC 02T .0105(1)]
V. INSPECTIONS
1. The Permittee shall provide adequate inspection and maintenance to ensure proper operation of the
wastewater treatment and irrigation facilities. [ 15A NCAC 02T .0108(b)]
2. The Permittee or their designee shall inspect the wastewater treatment and irrigation facilities to prevent
malfunctions, facility deterioration and operator errors resulting in discharges, which may cause the
release of wastes to the environment, a threat to human health or a public nuisance. The Permittee shall
maintain an inspection log that includes, at a minimum, the date and time of inspection, observations
made, and any maintenance, repairs, or corrective actions taken. The Permittee shall maintain this
inspection log for a period of five years from the date of the inspection, and this log shall be made
available to the Division upon request. [ 15A NCAC 02T .0108(b)]
3. Any duly authorized Division representative may, upon presentation of credentials, enter and inspect
any property, premises or place on or related to the wastewater treatment and irrigation facilities
permitted herein at any reasonable time for the purpose of determining compliance with this permit;
may inspect or copy any records required to be maintained under the terms and conditions of this permit,
and may collect groundwater, surface water or leachate samples. [G.S. 143-215.3(a)(2)]
VI. GENERAL CONDITIONS
1. Failure to comply with the conditions and limitations contained herein may subject the Permittee to an
enforcement action by the Division in accordance with North Carolina General Statutes 143-215.6A to
143-215.6C. [G.S. 143-215.6A to 143-215.6C]
2. This permit shall become voidable if the permitted facilities are not constructed in accordance with the
conditions of this permit, the Division approved plans and specifications, and other supporting
documentation. [ 15A NCAC 02T .0110]
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3. '['his permit i!s effective only with respect to the nature and Volume of wastes described in the permit
application, Division approved plans and specifications, and other supporting docurnentation. No
variances to applicable rules governing, the construction or operation of the permitted facilities are
granted, unless specifically requested arid approved in this permit pursuant to 15A NCAC 02T 01 05(n),
[G,S, 14,-2 15, 1 ]
4, The issuance of this permit does not exempt the Permittee from complying with any, and all statutes,
rules, regulations, or ordinances, which may be imposed by other jurisdictional government agencies
(e.g., local, state, arid 6ederal). Of particular concern to the Division are applicable river buffer rules, in
15A NCAC 02B .0200; erosion and sedimentation control requirements in 15A
5A NCAC Chapter 4 arid
under General l"Iermit NCG010000; any reqUirernents, pertaining to wetlands under 15A NCAC 02B
.0200 and 02H .0500; and documentation of compliance with Article 21 Part 6 of Chapter 143 of the
(-"icneralStatutes. tl5ANCACO2T,0105(c)(6)]
In the event the permitted facilities change ownership or the Permittee changes their name, a formal
permit modification request shall be submitted to the Division. "this request shall be made on official
Division forms, and shall include appropriate property ownership documentation and Other supporting
documentation as necessary. The Flel-Irnittee of record shall remain fully responsible for maintaining
and operating the facilities permitted herein until a permit is issued to the new, owner, [ I 5A NCAC
02T .O 104]
6. The Perinittee shall retain a set of Division approved plans, and specifications forthe life ofthe facilities
permitted herein. [ 15A NCAC 02T .0108(b)(1)]
The Pertnittee shall maintain this permit until all permitted facilities herein are properly closed or
pennitted under another permit issued by the appropriate permitting authority, [15A NCAC 02T
,O I 05(j)]
8. This permit is subject to revocation or unilateral modification upon 60 days' notice from the Division
Director, in whole or pail for therequirements listed in 15A NCAC 021" ,O I I O[ 15A NCAC 02T.0 I 10]
9. Unless the Division Director grants, a variance, expansion of the permitted facilities contained herein
shall not be granted if the Permittee exemplifies any ofthe criteria in 15A NCAC 02T.0120(b), [15A
NCAC 02T A 1201
I OThe Permittee shall pay the annual fee within 30 days after being billed by the Division. Failure to pay
the annual fee according].), shall be cause for the Division to revoke this permit, t I 5A NCAC 02T
.0 1 05(c)(3)]
I)ermit issued this the 30"' day of January 2017
NORTH CAROLINA ENVIRONMENTAL MAN AGEMENTCOMMISSION
'Ooel
7-lay Zimmerman, 11,(3., Director
Division of Water Resources
By Authority of the Environmental Management Commission
Permit Number WQOO�33,896
WQ0033896 Version 2.0 Shell Version 151201 Page 6 of 6

State of North Carolina
R Ue t t ru t dN
24�.� par rnen o t:v�ranrnen an MUM Resources
Division of Water Resources
15A NCAC OZT .06llti -SINGLE-FAM�! RES[DENCE WASTEWATER IRRIGATION SYSTEMS
,W,R
iy01�'fltSC�aU�j OPERATION AND MAINTENANCE AGREEMENT
pivisivtt! of Water ResourcesPew n9 FORM: SFRWWIS O&M 08-13
Permit No.� C O 3 3 S `t L
Property owner(s
Mailing address:
Facility address:
Irrigation Method
T
County: Fle V k d - >-
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. [A The 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 larnp(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 Pennittee"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 appearinp_ on the legally recorded Property deed shall sign this ODeration_& Maintenance Aereernent
I / We understand the above requirements and agree to these terms as part of the issued permit.
Owner Signature: Date:
Owner Signature: Date:
FORM: SFRWWtS O&M 08-1) Page 1 of 1

State of North Carolina
RECEIVED 1 DENR rtment of Environment and Natural Resources
;
Aquifrr D-.,F—inn SecWn Division of Water Quality
JUL 2 i 2Q09 SETBACK WAIVER FORM
g
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
t�
The Division of Water Quality will not consider this attachment form to be complete runless all the
instructions are followed. Failure to follow the instructions or to submit all of the required items
will lead to additional procesdng and review time for the application.
RMM
For more information or for an ekctronic version of this form, visit our web site
http.-IA2o.enr..rtrtte.nc.u&4audopplications.hmd
INSTRUCTIONS TO THE APPLICANT:
■
A. Attachment Form:
✓ Do not nibatit this attachment form for review without a corresponding Land Application Unit
oe°m
application form.
• : "
✓ Any changes to this attadhment form will result in the application package being returned.
u a
Any other setbacks required by 15A NCAC2T .0506 and .0606 other than those referenced below, cannot
be waived through execution of this form.
✓ A copy of the completed and appropriately executed form must be provided to the property owner.
•
m
AGREEMENT TO WAIVE THE SETBACK REQUIRED BY
15A NCAC 2T .0506(a), .0506(b) atld .0606(a)
The undersigned property owner(s) hereby permits:
Applicant's name: Elizabeth Fussell
Complete mailing address of applicant: PO Box 2 507
City: Surf City State: NC Zip: 28445
Telephone number: (910) 32 8 - 4141 Facsimile number:
hervinatter referred to as the Permittee, to (check all that apply):
® Irrigate wastewater within 3 9 feet of the property line,
❑ Irrigate wastewater within feet of the identified residence,
0 Construct wastewater treatment units within 10 feet of the property line,
as shown on the attached Wrap and located at the following:
Location address of property:
City: Holly Ridge
Belt Road (Pin No: 4236-50-1773-0000)
State: NC Zip: 28445
I certify that I am a deeded property owner of above -referenced property and am authorized to make
decisions regarding this property on behalf of other deeded property owners. Furthermore, I certify
that I have read and understand this Agreement and do hereby grant permission to the Permitter to
irrigated wastewater or construct wastewater treatment units as specified herein. I further agree that
upgn issuance of a pplm1it by the Di 'sion for -the wastewater irrigation system I record this
waiver form with the gppLo=atc Register of Deeds and provide the Pexmiam with documentation of
such_
Propertyowner(s)oame(s): Elizabeth B. Fussell
Signature-. `• Date: - _ 0
Signature: Date: i b ,Q -3 -o `�

lllllllfillllllllll�III�I�Illl�llllll a37�eKIN o2ti2M0c
Pander County, NC Reglaier of Duds page 2 of 2
STATE OF hLIt Lj�,, COUNTY OF p y�
I' � ,' , r A NOTARY PUBLIC IN AND FOR THE
A FORESAID COUNTY AND STATE DO HEREBY CERTIFY THAT
PERSONALLY APPEA16 BEFORE ME
THIS DAY AND BEING DULY SWORN DO HEREBY ACKNOWLEDGE THE DUE EXECUTION OF
THE FOREGOING INSTRUMENT FOR THE PURPOSES TiEREIN STATED.
THIS _2.3_DAY OF t n 1��W
+� ��a' (SEAL)
(NOTARY SIGNATURE)
(SEAL)
MY COMMISSION EXPIRES: a ai3,
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