WQ0000886_Application_20221101

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State of North Carolina
Department of Environmental Quality
Division of Water Resources
I 5A NCAC 021',060,01-SINGI,E-FAMILY RESIDENCE
WASTEWATER IRRIGATION SYSTEM - RENEWAL
FORM: SFRWWIS-R 012-21
Pursuant to 15A NCAC" .02"r 01L)71h)" if the application (foes 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
NCACO2T 0100, f5A -NCA(.' 02'1" .0600, ind Division Policies. For more information, visit the Water Quality Perrrultting
Section's Non -Discharge Brancti website. The Applicant shall subunit an electronic copy of the application and attachments
uploaded as a single Portable Documeniorjnat (PDF) rile to litips-8cdo -.11ranch-Sulinittal-
Forsn-Vei-2, or emailed toN(if less than 20 inegabytes (:Mfg'").
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SECTION I - APPLICANT INFORMATION
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1. Applicant: Michael C. Hillard
2. Permit No,: WQ01000886
3. signature authority,. Michael C. 1-fillard Ntle:
4. Mailing address: P.O. Box 128
City: Thomasville State: NC Zip: 2736
5, Contact person: Michael C. Hillard Emafl: niglitti-�aitino'9(�t?,)ralioo.coni
Pdrnary phone number, [phone] Office Secondary phone number: (336) 3 13,-3172 Horne
16. Secondary Contact person: 5 s 0, k (,e Ein aj 1: 1 v Yee A� Ccek�
Priniary phone nurnber: (3 36)lt; -3 a Select Secondary phone n uni ber: -3 igy Se lect
L-11-11111-1-11.1- -1111-1.11 1111-111,111 � 1-111111.11-11 -.I---
I. physical address: 2871 Old Hwy 29
City: Thornasville
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I, Billin address: P.O, Box 128
City.- Thoniasville
SECTIONH - FACILITY INFORMATION
County: Davidson
SECTION III - BILLINGINFORMATION
2, Verifthe Applicant does not have any overdue annual fees:
State: NC
Zijx 27360-7842
t my -IL ot
,2f UA t�yyq 1, A
Pursuant to 15A NCAtoy T,0 1201ju,.1, pennits for renewingfacilities shall not be granted if the Applicant or any affiliation has
all Unpaid annual fee.
FORM, SF'RWWIS-R 02-21 Page I o f 4

SECTION IV - OPERATION AND NIA'wrENANCE AGREEMENT
Permit Mm WQ,0000886
Permiltee: Michael C, Hillard (i.e., all deeded property owners)
County: Davidson
The Pennittee agrees to operate and maintain the single-family residence wastewater treatment and irrigation sy'stern as
folio-vvs:
I. Inspect the septic tank annually, and pump ou!t solids as needed,
1 inspect and clean tile, septic tank effluent filter annually. ffqydicabli)
3Inspect the tablet chlorinator weekly. Add wastewatergrade chlorine tablets (e.g., calcium hypochlorite) as needed,
Swininting pool grade chlorine tablets are not acceptable. Qf qj)plicable)
4, Inspect tile ultraviolet disinfection unit weekly, Clean or replace tile lamps and quartz sleeves as needed. Qf
upl?ficable)
5. Inspect all storage tanks, PLIMPS, and alarn-is niontilly, Renlove tile floating scurn layer in alli pump/storage tanks
when pumping, the septic tank solids out,
6, Inspect the spray irrigation systern nionth ly to verity,: proper operation or the spray ]leads; that there are no leaks;
that vegetative grow,th does not obstruct the spray heads; that the: irrigated wastewater is not ponding if] or running
oll'the designated irrigation area; and that there are no objectionable odors, Q1'q[)j)1ictfb1e)
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 tile irrigated wastewater is not ponding in or running off
ti'le designated irrigation area; and that there are no objectionable odors. (Y'4q)j,7/icub1e)
8. Maintain as set of Division -approved engineering plans and specifications,
9. Pay the required allnUal fee.
M Request renewal of this perm it on Division -approved forms no later than 180 days prior to expiration,
I I . Sign and ula appfic ti(lit0ai,i)ff"uttireowjieroftliesirigle-,faii,iilyresideiieewa,stem(ater*
treatment and irrigation systern for their completion and submission to the Division of Water Resources,
[/We understand (lie above requirements and agree to these terms as part of tile issued permit.
Signature:
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Signaturel- Date:
Signature: Date:
Signature: Date:
All deeded rE2p:)ert owner, s shall sign this Operation and M.aintemance
y -"!:
.�eemejlt
FORM: SFRM/W]S-R 02-21 Page 2 of 4

ATTACHMENT A -- SITE MAP
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Was the facility originally pennitted or had maJor modification issued after September 1, 2006?
'es - PUrsuant to d5A N(�,AC 02TJ) W5 i), sua bmit site reap pursuanten to the requirements in l 5021604 A NCAC ',,0Lt), These
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requirements are:
El A scaled map of the site with topographic contour intervals not exceeding 10 feet o,r 25 percent of total site relief and showing
all facility -related structures and fences within the wastewater treatnient, storage, and irrigation areas,
El Soil mapping units shown on all irrigation sites.
El The location of all wells (including usage and construction details, if available), streams (ephemeral, intennittent, and
perennial), springs, lakes, ponds, and other surface drainage features within 500 feet of all wastewater treatment, storage,
and irrigation'sites.
* Delineation oli compliance and review boundaries per 15A NCAC'021, J)107 and J) II fir 8, and l 5A N( "ACO2T .Qti,01,
* Setbacks as req u ired by 15 A N1 C, A C02T 060 ,
Eli Site property boundaries Nvithin 500 feet ofallwastewater treatment, storage, and irrigation sites,
El All habitable residences or places of public assembly within, 50O feet of all treatment, storage, and irrigation sites.
No - Skip Attachment A.
ATTACHMENTB -SIGNATURE AUTHORITY DELEGATION
Does the signature authority in Section 1, Item 3 meet the requirements pursuant to L5 NK-A 1, �1' t 'V .0 1.06(t,
,A_
Yes m Skip Attachment B,
El No Submit a deleg 00n lenex pursuant to 15A N(,",AC.02T_-0 l 06 I'll, ­ "I'll ­ __ - _� 1, _-, ""1 ­­­1 1___1 ___ (�,), authorizing the signature authori ty to si gn
ATTACHMENTC -FLOW REDUCTION
Does the existing pen -nit include an approved flow reduction?
Yes . Submit a copy of the flow reduction approval letter, as well as the nleasured monthil)(average aniount of wasitewater flow
contributed pet, uniffor the 12 months prior to permit renewal. Ifany ofthese monthly averages are within 20%6 ofthe approved
flow reduction value, the Permittee shall provide as reevaluation of the reduced flow value pursuant to the requirements in
9 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 systern?
M Yes -- Skip Attachment D.
El 'No - Pursuant to " I ' 5 " A N(-' - ACO2 I ( `)j_ 6(),, 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 systern on.
property not owned by the Perinittee.
ATTACHMENTE - AFFILIATIONS
Are the Pennittee's affiliations of'record comect? Check affilimions.
Yes -- Skip Attachment F " No - Provide the corrected affiliations and their contact information,
ATTACHMENT F - COMILIANCE SCHEDULES
Does the existing permit include any Compliance Schedules? (See Section I ofthe most recently issued permit),
El Yes - Submit documentation that the compliance schedules have been met.
[K No , Skip Attachnient F,
FORM: SFRWWIS-R 02-21 Page 3 of 4

A'r'TACHMENT — CIVIL PENALTIES AND OIJTSTANDtNG VIOLATIONS
Does the Permittee have any existing civil penalties or outstanding violations?
Ej Yes (civil penalties,) - Submit paynient for the civil penalty, or proof of remission request,
El Yes (violations) - Submit a copy of your response to, the Notice of Violation.
R No — Skip Attachment G,
ATTACIINIEN'T H — SETBACK. WAIVERS
Does the existing permit include setback waivers'.,'
El Yes --- pursuant to 1 5A NQ'AC 1 021 0606(.t.,,), 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 �5A NCA(" ' 02 L 0 107
K No SkipAttachnient fl,
APPLICANT'S CERTIFICATION
attest that this application
(Signature as lhorjty's natne as noted in Section 1, Itern 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 l 5A N(,/V"L02"', S), 2() drat the applicant, or any
parent, subsidiary. or other affiliate of the applicant has; not been convicted orenvironmental, critnes 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. pet-rnil, settlement agreement, or order; not paid an atnitial fee.
Note. The Applicant's Certffication shall be signed, pursuant to 15A NC'A(.02T-.Q 106 An alternate person may be delegated as
the signing official if a letter is provided pursuant to t 5A.ryrqC/k("02]'_,() [0 Pursuant to, § and § �.-'13-2 d 5,6B, any
person who knowingly makes any false staternent, representation, or certification in any application package shall be guilty ofa, Class
21nisderneanor,which may inckide a fine not to exceed $10,000 as, well as civil penalties tip to $25,000 per violation,
Signature: Date:
,rU[E COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email: Laserfiche Upload-
Non-pkcJnnar° a �� Lsu,' am - 11 - IYOS, locsAv -ou"MI/E lns/N Ili - in L A hm I tAnaluk
Stibmittal-1, oi-m-Aler2
FORM: SFRWWIS-R 02-2 l Page 4 of 4