WQ0002342_Application_20220809

Initial Review
Reviewer Thornburg, Nathaniel D
Is this submittal an application? (Excluding additional information.)*
Yes No
Permit Number (IR) * WQ0002342
Applicant/Permittee Gabriel D. and Sarah A. Sams
Applicant/Permittee Address 1018 Mountainside Ln. Burlington NC, 27217
Is the owner in BIMS? Yes No Is the facility in BIMS? Yes No
Owner Type
Facility Name
County
Fee Category Single -Family Residence
Is this a complete application?*
Yes No
Signature Authority
Signature Authority Title
Signature Authority Email
Document Type (if non -application)
Email Notifications
Individual
1018 Mountainside Ln. SFR
Alamance
Does this need review by the hydrogeologist? * Yes No
Regional Office
CO Reviewer
Admin Reviewer
Fee Amount $0
Complete App Date 08/09/2022
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* Gabriel Sams
Email Address*
[e-mail]
Project Information
Application/Document Type*
New (Fee Required)
Modification - Major (Fee Required)
Renewal with Major Modification (Fee
Required)
Annual Report
Additional Information
Other
Phone Number*
3366016630
Modification - Minor
Renewal
GW-59, NDMR, NDMLR, NDAR-1,
N DAR-2
Residual Annual Report
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.
hftps://edocs.deq.nc.gov/Forms/NonDischarge_Monitoring_Report
Perm it Type:*
Wastewater Irrigation
High -Rate Infiltration
Other Wastewater
Reclaimed Water
Closed -Loop Recycle
Residuals
Single -Family Residence Wastewater
Other
Irrigation
Permit Number: *
WQ0002342
Has Current Existing permit number
Applicant/Permittee*
Gabriel D. and Sarah A. Sams
Applicant/Permittee Address*
1018 Mountainside Ln. Burlington NC, 27217
Facility Name*
1018 Mountainside Ln. SFR
Please provide comments/notes on your current submittal below.
Hello, I have just purchased the property at the above listed address and was told by the
former owner I needed to submit this form. Please let me know what else if anything needs to
be done or changed. Thanks
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 Plans, Specifications, Calculations, Etc.)
SFRWWIS-CO-03-21.pdf 244.1 KB
Upload only 1 PDF document (less than 250 Me). 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
Submission Date 8/9/2022

Department 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 .01009 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.2ov/Forms/NonDischar2e-Branch-
Submittal-Form-Vert, or emailed to Non-Discharge.Reportsna- ncdenr.gov if less than 20 megabytes (MB).
SECTION I —
APPLICANT INFORMATIO
1.
Applicant: Gabriel Sams
2.
Permit No.: WQ00
3.
Signature authority: Gabriel Sams
Title: Owner
4.
Mailing address:
City: 1018 Mountainside Ln. Burlington
State: NC Zip: 27217 -
5.
Contact person: Gabriel Sams
Email: sams lg_3&amail.com
Primary phone number: ( 336 ) 601 - 6630
Secondary phone number: ( ) -
6.
Secondary Contact person: Sarah Sams
Email: s.sams413&=ail.com
Primary phone number: ( 336 )601 - 4064
Secondary phone number: ( ) -
SECTION 11 —FACILITY INFORMATION
1. Physical address: 1018 Mountainside Ln. County: Alamance
City: Burlington State: NC Zip: 27217 -
III — BILLING INFORMATION
1. Billing address: 1018 Mountainside Ln.
City: Burlington State: NC
SECTION IV — DEED INFORMATION
Zip: 27217 -
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.
No — See Attachment B on Page 3.
1. Parcel No.: 156116
3. Deed Book: 510
2. Date of Purchase: July 18, 2022
4. Deed Page Nos.: 564
FORM: SFRWWIS-CO 03-21 Page 1 of 3

SECTION V — OPERATION AND MAINTENANCE AGREEMENT
Permit No.: WQ00
Permittee: (i.e., all deeded property owners)
The Permittee agrees to operate and maintain the single-family residence wastewater treatment and
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 pennit.
Signature: A J'J(�'
Signature:
Signature:
Signature:
Date: 08/08/2022
Date: 08/08/2022
Date:
Date:
All deeded property owners shall sign this Operation and Maintenance Agreement
FORM: SFRWWIS-CO 03-21 Page 2 of 3

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
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 Gabriel Sams attest that thi
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: Date: 08/08/2022
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email:
Laserfiche Upload:
Non-Discharge.Reportsnncdenr.gov
https: //edo cs.deg.nc.gov/Forms/NonDischarge-Branch-
Submittal -Form -Vert
FORM: SFRWWIS-CO 03-21 Page 3 of 3