WQ0012264_Renewal Application_20221003

Initial Review
Reviewer Thornburg, Nathaniel D
Is this submittal an application? (Excluding additional information.)*
Yes No
Permit Number (IR) * WQ0012264
Applicant/Permittee David D. and April R. Harris
Applicant/Permittee Address 4257 Antioch Church Road
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
4257 Antioch Church Rd. SFR
Person
Does this need review by the hydrogeologist? * Yes NO
Regional Office
CO Reviewer
Admin Reviewer
Fee Amount $0
Complete App Date 10/03/2022
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* David Harris
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*
3362151337
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: *
WQ0012264
Has Current Existing permit number
Applicant/Permittee*
David D. and April R. Harris
Applicant/Permittee Address*
4257 Antioch Church Road
Facility Name*
4257 Antioch Church Rd. SFR
Please provide comments/notes on your current submittal below.
We have filled out what we assume is required if additional info is needed please let us know.
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.)
SFRW W I S-R-02-21. pdf 66.4KB
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
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Submission Date 9/30/2022

State of North Carolina
Department of Environmental Quality
Division 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 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 tohttps://edocs.deq.nc.gov/Forms/NonDischarge-
Branch-Submittal-Form-Ver2, or emailed to [e-mail] less than 20 megabytes (MB).
SECTION I –APPLICANT INFORMATION
1.Applicant: David Dylan Harris April Rose Harris
2.Permit No.: WQ0012264
3.Signature authority: DHTitle: MR
4.Mailing address: 4257 Antioch Church Road
City: TimberlakeState: NCZip: 27583-
5.Contact person: David HarrisEmail: [e-mail]
Primary phone number: [phone] CellSecondary phone number: ( ) - Select
Email:
6.Secondary Contact person: April Harris
Primaryphone number: [phone] CellSecondary phone number: ( ) - Select
SECTION II – FACILITY INFORMATION
1.Physical address: 4257 Antioch Church RoadCounty: Person
City: TimberlakeState: NCZip: 27583-
SECTION III – BILLING INFORMATION
1.Billing address: 4257 Antioch Church Road
City: TimberlakeState: ncZip: 27583-
2.Verify the Applicant does not have any overdue annual fees:
https://deq.nc.gov/about/divisions/water-resources/water-resources-permits/wq-epayments
Pursuant to 15A NCAC 02T .0120(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 1of4

SECTION IV – OPERATION AND MAINTENANCE AGREEMENT
County: Person
Permit No.: WQ0012264
Permittee: Dylan Harris , April Harris(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 gradechlorine 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 applicationto 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: Date:
Signature: Date:
Signature: Date:
Signature: Date:
All deeded property owners shall sign this Operation and Maintenance Agreement
FORM: SFRWWIS-R 02-21 Page 2of4

ATTACHMENT A – SITE MAP
Was the facility originally permitted or had a major modification issued after September 1, 2006?
Yes –Pursuant to 15A NCAC 02T .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.
ATTACHMENT B – SIGNATURE AUTHORITY DELEGATION
Does the signature authorityin Section I, Item 3meettherequirements pursuant to15A NCAC 02T .0106(b)?
Yes – Skip Attachment B.
No – Submit a delegation letterpursuant to 15A NCAC 02T .0106(c)authorizing the signature authority to sign.
ATTACHMENT C – FLOW REDUCTION
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 monthsprior 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.
ATTACHMENT D – EASEMENT, ENCROACHMENT, AND LEASE AGREEMENTS
Does the Permittee own all of the land associated with the wastewater collection, treatment, conveyance, and irrigation system?
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.
ATTACHMENT E – AFFILIATIONS
Are the Permittee’s affiliations of record correct? Checkaffiliations.
Yes – Skip Attachment E.
No – Provide the corrected affiliations and their contact information.
ATTACHMENT F – COMPLIANCE SCHEDULES
Does theexisting permit include any Compliance Schedules? (See Section Iof 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 3of4

ATTACHMENT G – CIVIL PENALTIESAND OUTSTANDING VIOLATIONS
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.
ATTACHMENT H – SETBACK WAIVERS
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.
APPLICANT’S CERTIFICATION
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 ofthis
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 to15A NCAC 02T .0106(b).An alternate person may be delegated
as the signing official if a letter is provided pursuant to 15A NCAC02T .0106(c).Pursuant to §143-215.6Aand §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:
THE COMPLETED APPLICATION ANDATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILEVIA:
Email:Laserfiche Upload:
https://edocs.deq.nc.gov/Forms/NonDischarge-Branch-
[e-mail]
Submittal-Form-Ver2
FORM: SFRWWIS-R 02-21 Page 4of4