WQ0012264_More Information Received_20221012

Initial Review
Reviewer
Thornburg, Nathaniel D
Is this submittal an application? (Excluding additional information.) *
Yes No
If not an application what is the submittal type?* Annual Report
Residual Annual Report
Additional Information
Other
Permit Number (IR) * WQ0012264
Applicant/Permittee David D. and April R. Harris
Email Notifications
....... ........ ......... ............
Does this need review by the hydrogeologist? * Yes No
Regional Office
CO Reviewer
Admin Reviewer

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* Dylan 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 Address*
4257 Antioch Church Road
Facility Name*
4257 Antioch Church 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 [e-mail].
Please attach all information required or requested for this submittal to be reviewed here. *
(Application Form, Engineering Plans, Specifications, Calculations, Etc.)
SFRWWIS-R-02-21 PDF.pdf 423.3KB
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
Submission Date 10/12/2022

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-R02-21
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 attachmentsshall be prepared in accordance with 15A
NCAC 02T .0100,15A NCAC 02T .0600, and Division Policies. For more information, visit the Water Quality Permitting
-Discharge Branch website.The Applicant shall submit anelectronic 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: Dylan Harris
2.Permit No.: WQ0012264
3.Signature authority: Title: Mr
4.Mailing address: 4257 Antioch Church Road
City: RoxboroState:NCZip: 27583-
5.Contact person: Dylan 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: RoxboroState:NCZip: 27583-
SECTION IIIBILLING INFORMATION
1.Billing address: 4257 Antioch Church Road
City: RoxboroState: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 02-21Page 1 of 4

SECTION IV OPERATION AND MAINTENANCE AGREEMENT
County: Person
Permit No.: WQ0012264
Permittee: Dylan 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 noleaks; 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-approvedengineering 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.
10-12-2022
Signature:Date:
10-12-2022
Signature:Date:
Signature:Date:
Signature:Date:
All deeded property owners shall sign this Operation and Maintenance Agreement
FORM: SFRWWIS-R 02-21Page 2of 4

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 authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)?
Yes Skip Attachment B.
No Submit a delegation letter pursuant 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 months prior 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
f record correct? Check affiliations.
Yes Skip Attachment E.
No Provide the corrected affiliations and their contact information.
ATTACHMENT F COMPLIANCE SCHEDULES
Does the existing permit include any Compliance Schedules? (See Section I of 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 3 of 4

ATTACHMENT GCIVIL 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 HSETBACK WAIVERS
Does the existing permit include setback waivers?
YesPursuant to 15A NCAC 02T .0606(c), provide setbacks waivers that have been written, notarized, signed by all parties
involved, and recorded with the countyRegister of Deeds. Waivers involving the compliance boundary shall be in accordance
with 15A NCAC 02L .0107.
No Skip Attachment H.
Dylan Harris
I, attest that this application
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.
NoteCertification 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.
10-12-2022
Signature: Date:
THE COMPLETED APPLICATION ANDATTACHMENTS SHALL BE SUBMITTEDAS A SINGLE PDF FILEVIA:
Email:Laserfiche Upload:
https://edocs.deq.nc.gov/Forms/NonDischarge-Branch-
[e-mail]
Submittal-Form-Ver2
FORM: SFRWWIS-R 02-21Page 4of 4