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Home My WebLink AboutWQ0018423_Application_20220615 Non-Discharge Branch Upload/Submittal Form NORTH CAROLINA EnMentalQuuuty Version 2-Revised June 23,2020 Initial Review Reviewer Thornburg,Nathaniel D Is this submittal an application?(Excluding additional information.)* Yes No Permit Number(IR)* WQ0018423 Applicant/Permittee William E.Goldman and Virginia L.Miller Applicant/Permittee Address 8087 Wake Road,Durham,NC 27713 Is the owner in BIMS? Yes No Is the facility in BIMS? Yes No Owner Type Individual Facility Name 8087 Wake Rd.SFR County Chatham Fee Category Single-Family Residence Fee Amount $0 Is this a complete application?* Yes No Complete App Date 06/15/2022 Signature Authority Signature Authority Title Signature Authority Email Document Type(if non-application) Email Notifications Does this need review by the hydrogeologist?* Yes No Regional Office CO Reviewer Admin Reviewer Below list any additional email address that need notification about a new project. Email Address Comments to be added to email notfication Comments for Admin Comments for RO Comments for Reviewer Comments for Applicant Submittal Form Project Contact Information Please provide information on the person to be contacted by NDB Staff regarding electronic submittal,confirmation of receipt,and other correspondence. ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ Name* William Goldman Email Address* Phone Number* wgoldmangm@gmail.com 9192658736 Project Information Application/Document Type* New(Fee Required) Modification-Minor Modification-Major(Fee Required) Renewal Renewal with Major Modification(Fee GW-59, NDMR,NDMLR, NDAR-1, Required) NDAR-2 Annual Report Residual Annual Report Additional Information Change of Ownership Other 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.deg.nc.gov/Forms/NonDischarge_Monitoring_Report Permit Type:* Wastewater Irrigation High-Rate Infiltration Other Wastewater Reclaimed Water Closed-Loop Recycle Residuals Single-Family Residence Wastewater Other Irrigation Permit Number:* WQ0018423 Has Current Existing permit number Applicant/Permittee* William E.Goldman and Virginia L.Miller Applicant/Permittee Address* 8087 Wake Road,Durham,NC 27713 Facility Name* 8087 Wake Rd.SFR Please provide comments/notes on your current submittal below. At this time,paper copies are no longer required.If you have any questions about what is required,please contact Nathaniel Thornburg at nathaniel.thornburg@ncdenr.gov. Please attach all information required or requested for this submittal to be reviewed here.* (Application Form,Engineering Plans,Specifications,Calculations,Etc.) changeowner.pdf 5.54MB Upload only 1 PDF document(less than 250 MB).Multiple documents must be combined into one PDF file unless file is larger than upload limit. * 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 fi�rr'' �yv[ A+c Heaor Submission Date 6/14/2022 State of North Carolina DWRDepartment 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.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 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.deq.nc.gov/Forms/NonDischarge-Branch-Submittal- Form-Vert,or emailed to Non-Discharge.Reports(a,ncdenr.gov if less than 20 megabytes(MB). SECTION I—APPLICANT INFORMATION 1. Applicant:William E.Goldman 2. Permit No.:WQ0018423 3. Signature authority:William E.Goldman Title:Owner 4. Mailing address:8087 Wake Road City:Durham State:NC Zip:27713- 5. Contact person:William E.Goldman Email:wgoldmangm@gmail.com Primary phone number: (919)265-8736 Cell Secondary phone number:(919)966-9580 Office 6. Secondary Contact person:Virginia L.Miller Email:vlmiller@med.unc.edu Primary phone number:(919)265-8735 Cell Secondary phone number:(919)966-9956 Office SECTION II—FACILITY INFORMATION 1. Physical address: 8087 Wake Road County: Chatham City:Durham State:NC Zip:27713- SECTION III—BILLING INFORMATION 1. Billing address: 8087 Wake Road City:Durham State:NC Zip:27713- 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 1 through 4 below. E No—See Attachment B on Page 3. 1. Parcel No.:79396 2. Date of Purchase:November 24,2021 3. Deed Book:02266 4. Deed Page Nos.:0357-0359 Permit No.: WQ0018423 County: Chatham Permittee: William E.Goldman and Virginia L.Miller(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. I/We understand the above requirements and agree to these terms as part of the issued permit. Signature: ¿t/L4:t.vt £. Date: 6/r/2 0 2 Z Signature: °`"li /11( Date: 69 ó 09'9N Signature: Date: Signature: Date: All deeded property owners shall sign this Operation and Maintenance Agreement 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(f)(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 I, WV 1 Rrn C=, C,ohimav+ 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(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: W4.G4 q w. �� "�- Date: 4,1/2 0 2 2- THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA: Email: Laserfiche Upload: Non-Dischar e.Reports(a ncdenr. ov https://edocs.deq.nc.gov/Forms/NonDischarge-Branch- Submittai-Form-Vert