WQ0014560_Application_20221027

State of North Carolina
C Department of Environmental Quality
ept of Environmental Quality Division of Water Resources
Division of Water Resources C T 2 515A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE
WASTEWATER IRRIGATION SYSTEM- RENEWAL
FORM: SFRWWIS-R 02-21
Pursuant to I SA NCAC2 00 7{ 1, 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 1
CAC 02T.0100 15A NCAC 02T , 6 , 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 t s:foe oes, a c. ov or s o ischarae® rant -Su i a -
or -Vert, or emailed to o - ischare. o s .nc enr. ov if less than 20 megabytes (MB).
1 Applicant
2. Permit No.: WQ00 I zi S'&D
3 Signature authority
4. Mailing address: 32011,
City:
a
Lo )Q(— t j� C LAt'f
5. Contact person: c: e,e f
Primary phone number: ((-11t4) - Select
6. Secondary Contact person: o�r��
Primary phone number: (4 k(w) - Select
1. Physical address:
City:
Title:
State: lUc, Zip: - _� (3
Email:
Secondary phone number: ( 1% - Select
Email:
Secondary phone number: ( ) - Select
SECTION III;— BILLING INFORMATION
1. Billing address: µ
City: M �� State Zip:-
2. Verify the Applicant does not have any overdue annual fees:
k��ilt "�d,att,t�i��,!P���°"ter r-r�tr�rc�s"ratter®rsres-per ii q,..11.t
Pursuant to 15A NCAC 021,0120 (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 1 of 4

Permit No.: WQ00 I H 5- (0 O
Permittee: (i.e., all deeded property owners)
County:
a,
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 Qhgngt2fDmpgshi ap lication 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: Date. 19
Signature: ,,,,,,,, Date:
1
Signature: Date:
Signature: Date:
All deeded property owners shall sign this O eration and Maintenance Agreement
FORM: SFRWWIS-R 02-21 Page 2 of

Was the facility originally permitted or had a major modification issued after September 1, 2006?
Yes Pursuant to 1, A C' ,,,, 2T .001,0� d , submit a site map pursuant to the requirements in l5 NCA w_02T v C 4 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 ...02.L.........0........1.....0......7 and .01 d 1 5A AC°.02...............06......0..1....
Setbacks as required by 15A NCA,,,02F .60.
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.
o Skip Attachment A.
Does the signature authority in Section I, Item 3 meet the requirements pursuant toA0 pObl ,f?
Yes Skip Attachment B.
❑ No Submit a �lgle a s n qq r pursuant to 15A NCAC 021,0106U authorizing the signature authority to sign.
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 ! A
Skip Attachment C.
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 Jj- m tw, 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.
Are the Permittee's affiliations of record correct?J1119q:
es Skip Attachment E.
❑ No — Provide the corrected affiliations and their contact information.
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.
or Skip Attachment F.
FORM: SFRWWIS-R 02-21 Page 3 of 4

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.
-- Skip Attachment G.
Does the existing permit include setback waivers?
❑ Yes Pursuant to 15A NCAC 2T .06 "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 02 .0107.
,0'10 -- Skip Attachment H.�
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 , 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 .0106Cbi. An alternate person may be delegated as
the signing official if a letter is provided pursuant to 15.A_ CAC 02T .0106(c}. Pursuant to § 1 3-215.6A and § 1 3-215.6B, any
person who knowingly makes any false statement, representation, or certification in any application package shall be guilty of a Class
2 misdemeanor, which ma include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
.m...m,
Signature: .............— Date:.._ ...
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email:
Non- isc e. eorts cdenr.eov
Laserflehe Upload:
htt s:Il ocs. a .ne. ov orms/No isc e- ranch -
Sub ttal-Form-Vert
FORM: SFRWWIS-R 02-21 Page 4 of 4