WQ0039211_Application_20220624

State of North Carolina
Department (if Environmental Quahty
Division of VN ater llcsour� es
Division of W,,,ter Re—sotor(es 15A NCAC 02T.0000 — SINCLE-FAICI ILY RESIDEN," E
WASTEWATER IRRIGAT ION SYS'l - 1U]NEW %L
FORM- SFRWNVIS-R 02 21
Pursuant to , if the application does nol include all required information and, the necessara supporf ng,
documentation, the application shall be returm.A. The appficution and attachments shall be prepared in accordal'we with
and . For more information, viAt the Water ()tjafitN Permjlt ng
Section's Non -Discharge Bran6i Thar Applicant shal submit an electronic copy ol the applicatiw'andatwelinit a,ts
uploaded as a single Portable Document Format (PDF) file to
or emailed to it' less tban, 20 mcgabytes (MB).
SECTION I — APPLICANT INFORMATION
I Applicant. ] om (,,olhoun
- - — - ------ -- . ... ..... . .. . ...... ....... ..
2. Permit No.: WQO;03921
Signature authority Tom (7( lhoun Title: NA,fler
.... . .. ...
J. Mailing addrew P0 Box 312
City Apex State: �k' Zip: 27S02-
. ........ .
5. (,ontacl person: Tom olhomi �'ojjj�(jCoj�jojjj­
itcaleslate,com
Pilmary phone number: (9 11) 924-4085 Selc,:t
Seconcar) phone numb�.-i":
. . .. . ...... . ..... . .. .. .. .. ....
6. Secondary Contact person: lAnda C01110LIA EmaH: APeNCa)IIIOL111(�i'.,,A,iiaii.corii
flrhnary phone number: (9 I 1,) 8l 8-473 SelecSecondury phone titan In r:
SECTION I] — FACILITY INFORMATION
. ... .......................
I. Physical address: 2 14 1-ody -joodwin Rd
City: Apex stale: Nc X ip: 27 502-
SECTION Ill — BILLING INFORNIATiON
1. BiHingaddrcss: P(.) Box 32C.
City. Ape\, slate: 1, C, Zip: 27502-
.2. Verify the Applicant does not haveam, overdue annuafees:
Pursuant to P011W"S for renewim, ;icihtics shall mt be arantcd H'Vie Applicant or m\ affih.mim h—s
an unpaid atmtW fee,
FORM: SFRWWIS-R O2-2B

SECTNON IV — OPERATION AN 0 MAINTENANCE AGREEMENT
. ............
Permit'No.: WQ003 )92 11 Cmmly: Chatham;
Perrnittee:Torn Colhomi 6.c- all deeded pr,)Pcrlv OM'Iei's'
The Permittee agrees to operate and maintain the single-l`arrfly and irril..atfoii S.\ item a
follows:
I, Inspect tlli2 septic lank aNlUalIV., and PL111113 out -sofids, needed.
2. Inspect and clean the ser tic tank CfflUCHt filter annualk.
3. Inspect tile tablet chlorimaor \\;ccklN, A]d waste\Nater irade chlorine ablets caximll lay pociflorite) as needec
Swimmim-, pool grade cl,, lorine tablets acre not acceptake, (i tijyVictib I 7 "1 e)
4. Inspect the ultraviolet disinfection urrir weekly. Cle wi or replace lie lamps and quartz sleeves as ncedC& o
o1)p1kWh1c)
1
5. Inspect aF storage tanks, PUMPS. and alarms nionthly. Remove tile Hoating scum Liycr in all j)ump/s1orag,-, tank,
when pumping the septic tank solids oir,
6. Inspect (he spray irrigation systern n1ow-111v to verify: woper operatkm of the sp-, - that thc,-e are nu leak�,
I - slur-, av heads.
that vegetative growwtlt d(ICS 110t ObStrUCI the spray hea(.�,-, that the irritated wvastcwatcr is not pondivg in or runniril
offthe designated irrigal on areaa-. and tLat there are no obj eel i oriable odors. (iful)jilhwh1e)
7. Inspect the drip irrjgatioif, systen'i montHy to verify: pi )per operation of the drip fines: that there atr no lc,17 ,-;: tha,
vegetative a vowth does, rim obstruct the ,]rip emitters., I rat the irrigated wastewater i,�, riot ponding ire Or rLITU141p, 01'
the designated irrigation irca, and that Caere are no obJ1,Ictionable odors. (ff(1jy)1icC1hw)
8. Maintain ar set of D,iN isio i-approved engineering plans mid specil'icati,l-Nis,
9. Pay the rojUired annual t-,e,
10. Request renewal of this 1, ernift on Dj\ ision-approved t orrns no later than 180 days prior to e\,pirad,n.
I I . Sign and provide a tC 'MIX fUtUre OW ter ol'the singlo,-l'amil-, reside sec w�,NcNV(AtC:
treatment and irrigation System for their conipletion an] Submission lo tile, Division of Water Resources.
Me understand the abo,\e requirements and agree to these terms as part ofthe issued perillit.
Date:
Signature: —"."L
Signature:
Signature:
Signature:
Date:
Date -
Date:
Allj( miedl pi opefty ownei-s shall sign tW,j_()L)erafiou ayid Maintenance Agreemen
FORM. SFRWVV1S-R 02-2 1
Pdx! ,.- 2 o

A SITE MAP
Was the facility originally permiaed or had as nia_or modification rssiared after Sepi,ember 1, 2006"
Yes- Pursuant to sUbmit a site ma I purtmnt to flit reqUireillellits jV
rqUirements are:
0 A scaled map of the site with topographic contour interva :, not exceeding 10 feet or 25 pci% �ent of renal site efiet'and ti,hovk u 9.
all facility -related %truciwes and fences xithirt the waste water treatment. storage, and ir6rafioli areas,
* Soil mapping units shot n on aH irrigation sites.
* The location of all w,we 15 (illClUding uage and coristri.clion details if available). stream
rns (ephemel-al. intern w d
perennial), springs, lakts, ponds, ajl� other SUrface draiiiage features wjJiin 5(' 0 feet of all waste)xater l.'eatment, storaq)
Z7
and hi-igabon sites.
* Dehnewion ofthie conij-hanceand revie,,%, boundaries pe and arld
El Setbacks as required by
0 Site property bouridarie,, within 500 feet of all Nvaslewait r treatment, stoiage. and irrigation sites.
El All li&table residences or places ofpublic assembly wiihin 500 feet ofaill treatment, storage. and irrigation
Z No - Skip Avachment A.
ATTACHMENT 8 - SIGNATURE AUTHORITV DELEGATION
. . ..... . . . .. . ...... . ......
Does the signature authorit in S,�ction 1, 1 tem 3 meet the reqUirC"hIC11tS purstlant to
Z7
Yes -Skip Attachnieril 13.
No - SUIN" it a purwant to authorizmp the signature authority to :sigh.
ATTACHMENT C - FLOW REDUCTION
. .. . ........ . .......
Does the CXiS61114 PCrIllit HIClUde all approved f1oN, reduction"
it Yes - Submit a copy of the Hmv reduction approval letter, as ,well as the niew"ured monthly, aw crage arnount wastewaLer flo
Z�
contributed per unit for the t I months prior to permit renewa' lfany ofthese monthly avUZILIOS are within 201,o of the OpPRM L I
flow rccluction value. the Ile °niittee shall provide as reevahiavoll of the reduced flow value pwsuant to the 1-CCIL61'011CMr , ill
17 No m. Skip Attachment C.
ATTACHMENT D - EASEMENT, ENCROACHMENT, AND LEASE ACREEMENTS
Does the Perm iuk!c own all ofthk land associated with the wasiev ater collection. , reatment. conve,,ance, and irl-h-ulion S\ sfa,nl?
Yes - Skip, Attachment 1).
No .,- Pursuant to prcwide a copy d'aH easements lease aureemcrts. and encroa&nlem d"reenien
a llowin _g the Permittee to o)crate and mah,min the w,asiewitcr collection. treatment, cony vknee , and irt-i!adon s\Stenii cI
property not owned bthe Pcrrnittee.
. . . . . .......... - -------
ATTACHMENT E - AFFILIATIONS
Are the Perrnilte,,�"s affifiation,'i o'record correct"
Z Yes,- Skip AttachmentE,
El No - Providc the corrected afifiations and Ill �ir contact inConiafion,
ATTACHMENT F - COMPLIANCE SCHEDULES
Does the eNisthiL,. Perl1lit 41CILIde _,my Cornpliance Sched Ll lies"? (Set Section I ofth( most recently issued perm ft)
Yes Submit documentation that the coniplkaice schedUICS li,we been met,
No Skip Attachment F.
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"'ORM: SFRWkVIS-R OY2-2 l f I a,-, C 3 c)

ATTACUMENT G - CIVIL PENALTiES AND OUTSTANDING VIOLATIONS
Does the Permitlee have airy exi�,ting civil penaltses or oulstandin � violations?
El Yes (civil pcnalties) Submit payment t6r tl,e civil penalty. r proof of remisiion request,
L-1 YeS (ViOldtiOFIS) - SUbmit as 1opy of your resoonse to the Not.ce ofVlolation.
No Skip Attachment 6.
. . . ...............
ATTACHMENT H - SETBACK WAIVERS
Does the existing permit include setback waivers.)
F-1 Yes -- Pursuant to . provide setbacw,s vwaivers that yiave been wriacn. notarized, sipied by aH parti, s
involved. and recorded with the counly, Reg:itcr of Deeds, V� aivers invoMn,i the cornpfianc�,, boundary sha�! be hi'ac,ordanoo
with
No - Skip Attachment H,
APPLICANT'S CERTIFICATION
. .... .. ..... . attest that this appficat4 °1
(Signatme authority's name aas noted in S,:cdon 1. Iten-i 3)
has been reviewed by me and is accurate and complete to the bc,t of my knowltdge. I understud diat ifaH recjiired pans ofill s
application package are not completed. and timt it' all recjuit°&k SUPPortinLx inf�,.)rmationi and wtachments are rant inckided, th s
application packaige will be returied as incomplete. l further cell t'y pursuant to that 01k, applicant. or ar
parent, subsidiarv. or other affil4ae ofthe applicalit has; not been r;,()nviued of cnvironniental crinici under- not prow imO% abandom J
a wastewater treMment t'acifil� wwlthotjt properl\ (la)sing the fiaciiii, not paid a civil penalty: not be,m compliant wifli an" compham
schedule in a permit, sefflement tiagrcemcm., or order: not paidan :nnual fee.
Note: The Appbcant's Cerflfica. ion shall be sigrtd pursuant to An alternate person nmN be (Mo-"-'ated
thesignino offlicial it's letter is provided pursuart to P'UrAiant to § and aB
misderneanor. which maN incli de a fine not lo-xceed SlO,000 is well) as civil p,maities up to $25.000 per Ootatloll,
Signatffe° d Dat
THr COMPLETED APPLIC ATION AND AJTAC H MENTS SHALL BE SUBMITTED AS A SINGLE I'DF FILE, VIA:
Earn all:
Laserfiche Upload:
FOM SFRWkk'lS-lZ 02-2 l P,,we 4 of I