WQ0031820_More Information (Received)_20211027

State ofN_orth_(_,'ar_ol'ma
DWR Department of Environmental Quality
Division of Water Resources
Division of Water Resources ISA NCAC 02T.0600 — SINGLE-FAXIIIX RESIDENCE
WASTLWATER IRRIGATION SYSTEM — CHANCE OF OWNERSHIP
FORM: SFRWAA'IS-CO 03-21
Pursuant to 15A NCAC 02T.01 07(bj, 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 IAA
NCAC 02T .0100, 15A NCAC 02T .0600, and Division Policies. For more information, visit the N�,ater Quality Permitting
Section's Non Discharge Branch Lvebsite. The Applicant shall submit 11" electronic copy of the application and attachments
oploaded as a single Portable Document Format (PDF) rile to httl)s://e(i()CS,(Ie(I.IIC.Cyolr arge Branch U 11
/Forins/NonDisch, -131 -S b, ittal-
,ov if less than 20 megabytes (MB).
Form-Vei% or emailed to 'N"on-Discharg Reports4unctlenr.L
SECTION I—
APPLICANTINFORMATION
1.
Applicant: Jose Magma Paredes and Andrea H. Magana
2.
Permit No.: WQ0031820
3.
SigniltUre IHM110111V: JOSC M�Iggoa PUcdcs, Andrea 11.
Ma-ana Title: Property ffivner. Operators
4.
Nlailingaddress: PO Box 297
Citv: Hillsborough
State-. NC Zip: 27278-
5
—
Contact person: Jose Magaim Paredes
tr
Email.- niaganajo(e(glna i 1. coil]
Primary phone iminber: [phone] Cell
Secondary phone ntinibcr: [phone] Cell
6.
Secondary Conlact person: Andrea H. Magana
Email: all-il 127(d�gniail.coin
Primary phone IlUmber: [phone] Cell
Secondary pholle numberl- [phone] Cell
SECTION 11
— FACILITY INFORMATION
1.
Physical address: 1717 Ormond Rd
County: Orange
City: Hurdle Mills
State: NC Zip: 2 7541 -
SECTION III —BILLING INFORMATION
1. Billingaddress: PO Box 297
City: Hillsborough
I State,- NC Zip: 27278-
SECTION IV — DEED INFORMATION
Has as deed been execritcd and recorded in the County Regisier of Deeds pUrStlallt to I7A NCAC 02T 0(04tc)(I1?
Yes -- Complete Items I tllrori&,li 4 below.
No — See Attachment B on Pape 3,
I Parcel No.: 9879-36-0784 2. Date of purchase: July 19, 2021
__ ...........
3. Deed Book: 6734 4. Deed Page Nos,-, 2133 ­ 2 134 (2)
n k) N A - q 1: 1? N I T Nh 1 T q - (- (-1 0 1 - -) I P""" I 'f"2

1­1 .... .... .. . .. '­ I
SECTION V — OPERATION AND MAINTENANCE AGREEMENT
C,'01.111ty', Orange
Permit No.: WQ0031820
Permittee: Jose Magana Paredes, Andrea H. Magana (i.e., ail deeded property owners)
The Pci-mittee agrees to operate and maintain the single-family residence wastewater treatment and irrigation system as
follows:
C' C ,":� ?-�
1. Inspect the septic tank annually, and pump out solids as needed. :I
2. Inspect and clean the septic tank effluent filter annually. (ifaplVicahle)
3. Inspect the tablet chlorinator weekly. Add wastewater grade chlorine tablets (e.(,,, calcium hypochlorl(e) as needed.
Swimming pool grade chlorine tablets are not acceptable. Q1'ajq)1iea171e)
XInspect the ultraviolet disinfection unit weekly, Clean or replace the lamps and quartz sleeves as needed. (if.
applicoble)
5. Inspect all storage tanks, pumps, and alarms monthly. Remove the floating scum layer in all pump/storage tanks
when puniping 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-,
irrigated wastewater is not ponding in or running
that vegetative growth does not obstruct the spray heads- that the irr'
off the designated irrigation area, and that there are no objcctionablc odors. (V'qpj)flecth1e)
7. Inspect the drip irrigation system monthly to verify: proper operation of the drip lines, that there are no leaks-, that
I
vegetative growth does not obstruct the drip emitters;irrigated that the irrigated wastewater is not ponding in or running off
C,
the designated irrigation area, and that there are no objectionable odors. (iftipplicable)
8. Maintain a set ofDivision-approved engineering plans and specifications.
I
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 0-wriershig app
lication to any future owner of the single-family reside
nce wastewater
treatment and irrigation system for their completion and submission to the Division of Water Resources,
C,
11"We understand the above requirement,; and agree to these terms as part of the issued permit.
Signature:
Signature:
Signature:
Signature:
Datc:
Date:
Date:
Date:
/C/
IOL251
All deeded Property owners shall sign this ODeration and Maintenance A2reement
(ZPPW"xx'T1C'_(1C) 01-')l pxl(­ ') «rl

ATTACHMENT A - SIGNATURE AUTHORITY DELEGATION
N10 sia�atttwe in Section 1, 11cm 3 meet the requirements pursuant to 15A NCAC 02T.011)(j(b)?
,� y
ttachment A,
1,Sut):111i*ij iLcic miion letter pursuant to 15A NCAC 0-1L,()L0()LC -izing the sioriature authority to sign.
L- _I Wither L,
ATTACOMENT B - PROPERTY OWNERSHIP DOCUMENTATION
1-las a deed been CXCCUtCd and recorded it) the County Register of'feeds pursuant. to 15A NCAC 02T .0604(fg I
Yes - Complete Items I through 4 in Section IV on Page I
No
F-1 Submit a written notarised inlem to purchase agrecillent sign by both parties willi j pj,,It or st.11-vey 111,1p pti.1-slia,11 to I 5A NCAC
02T 0604 2 -� or
ALL_j
rl Sa,ibiiiiti��-r,ieiciii)otiri/,edlease i,,reciiiciit(halt specii-icallyiiidieatestliciiiteiidedLase ofthe property aii.dhas been si,,nuclby
both parties, as well as a plal or survey map pursuarit to 15A NCAC 02L.(L6()4LeJL�� Le, se 3 1 agrectnents shall adhere to the
rQquirenienls of 15A NCAC 02L .0107.
_
APPLICANT'S CERTIFICATION
that this application
(Signature authority's name as 1'10fect it, Section I. Item, :,,)
has been revieNved by me and is XCI.Mlle and complete to the best of my knowledge. I understand that if'all requircd parts of this
application package are not compteled, and that if all required supporting information and attachments are not included, this
application package ivill be 17CUffned as illcolilpletc. I further certify PLU-SWUlt to 15A NCAC O"T .0120(b), that the applicant, or ariv
parent, subsidiary, orother affiliate of the applicant has: not been convicted 0fCnVir01l1llCn1',lI crimes under: not previously abandoned
-
a wastewater 11-caill lei) t facility without property closing the Iacility- not paid aCivil PCIIilly: not been compliant with any' coil] pli all cc
schedule in a permit. settlement agreement, or order- not paid an annual fee.
Note: The Applicant's Certification shall be signed purstmit to t5A NCAC 02T .0106(b). An alternate person may be delegated as
the sigmilig, officia I if a letter is provided pursuant to I SA NCAC 02T() 1 06(c). Pursuant to § 143-2 15.6A and § !4-' - --my
- _-215 t� .613,
person who knowingly makes any false statement, representation, or certification in any application package shall be gUilty Ofai CkIS.S
2 n.iisdC-rncfflIqA, Which MIV include 1-me not to exceed S,40 000
as well ',is civil penalties tip to $25,000 per violation.
sigrimure: DatcXz el
E ma i 1:
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Laserfiche Upload:
htti)s://e(locs.(Ie(l.tic.(-,oi,/Foriiis/Noi,iDisch,ir-ve-Br,tiich-
Suhrnittal-Form-VeI-2
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