WQ0030465_Renewal Application_20221108

Initial Review
Reviewer Thornburg, Nathaniel D
Is this submittal an application? (Excluding additional information.)*
Yes No
Permit Number (IR) * WQ0030465
Applicant/Permittee Sergio and Norma A. Salazar
Applicant/Permittee Address 1547 Andover Avenue, Greensboro, NC 27405
Is the owner in BIMS? Yes No Is the facility in BIMS?
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
2060 Stewart -Hutchens Rd SFR
Guilford
Does this need review by the hydrogeologist? * Yes No
Regional Office
CO Reviewer
Admin Reviewer
1'[ Ore
Fee Amount $0
Complete App Date 11/08/2022
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* Sergio Salazar
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*
336-362-7998
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
Permit Type: *
Wastewater Irrigation
Other Wastewater
Closed -Loop Recycle
Single -Family Residence Wastewater
Irrigation
Permit Number: *
WQ0030465
Has Current Existing permit number
Applicant/Permittee*
Sergio and Norma A. Salazar
Applicant/Permittee Address*
1547 Andover Avenue, Greensboro, NC 27405
Facility Name*
2060 Stewart -Hutchens Rd SFR
Please provide comments/notes on your current submittal below.
High -Rate Infiltration
Reclaimed Water
Residuals
Other
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.)
WO0030465_Applicaiton_20221108.pdf 281.25KB
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 11/8/2022

NC DepartMQRt 6 State of North Carolina
EnvironmenW Qolity Department of Environmental Quality
�tec.I�l��Pd Division of Water Resources
©tvlslon of Water Resources NKONi 0 7 2022 15A NCAC 02T .0600 -- SINGLE-FAMILY RESIDENCE
WASTEWATER IRRIGATION SYSTEM - RENEWAL
�Aflnston-Saie_m FORM: SFRWWIS-R 02-21
L 01 V I Id1 Ld Ffi,C -.
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 .01001 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 htt s:/ledoes.de .ne. ov/Forms/NonDischar e-Branch-Submittal-
Form-Ver2, or emailed to Non-Discharge.Reports(?,ncdenr.gOv if less than 20 megabytes (MB).
1.
Applicant: S e- -* L'' l n vi S o I,^ q
1�, C. � G er, k-
2.
Permit No.: WQ00 3 D 6 L
3.
Signature authority: S e V" (0 S-e, t G —.
Title: d w JAe ,✓
4.
Mailingaddress: 2 ©6 Q +e �= c v'• ­v
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City: h L �se_ 14
State: &)C , Zip: `z 7 3 ? 7
5.
Contact person: S �. �1 / e t Gz ev
Email:S y N Sq 142..n ri Z 9'"' { CCN'
Primary phone number: (?e)3e?- 7 (Meet
Secondary phone number: (I3,1)3u 7yVlelect
6.
Secondary Contact person: r, L I.,
�.f�G � t A-ZAY Email:Pe- Y 1� ES �'tr`ZC1Y._P:eMC,
Primary phone number: vd)W/30 elect
Secondary phone number: (374)SV elect
Physical address: /�� h V r -ve
County: V (I ✓
1.
City: G-yL' e OS �d r0
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State: NC Zip:
Billing address: / S~ L(7 A o Jove A` x_
t.
City: C ,.fie V1 �,, .xz,
State: AI` C Zip:�� - 4-f0
2.
Verify the Applicant does not have any overdue armual
fees:
htt s://de .nc.Qov/about/divisions/water-resources/water-resources- ermits/w -e a ments
Pursuant to L 5 A 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 1 of 4

Permit No.: WQ00
Permittee: (i.e., all deeded property owners)
County:
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)
S. 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 permit.
Signature: Date: D ��
Signature: Date:
Signature: Date:
Signature: Date:
All deeded property owners shall site this Operation and Maintenance Agreement
FORM: SFRWWIS-R 02-21 Page 2 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.
[K No - Skip Attachment G.
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
th 15A NCAC 02L .0107.
No - Skip Attachment H.
1 £` 1--412_(0 -_->v 4�zG
(Signature authority's name as noted in Section I, Item 3)
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 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 .0166(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: G Date:
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
EmaiU Laserfiche Upload:
https:Hedoes.,'.,- rye.gov/Forms/NonDischarge-Branch-
Non-Dischar ,rt,ns. enr.�ov Submittal-Form-Ver2
1�yh A I / S y n ")dc-17 619
FORM: SFRWWIS-R 02-21 Page 4 of 4

Was the facility originally permitted or had a major modification issued after September 1, 2006?
dyes — Pursuant to 1_5A 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.
Does the signature authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)?
dyes — Skip Attachment B.
❑ No — Submit a delegation letter pursuant to 15A NCAC 02T .0106(c) 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 15A
NCAC 02T .0114(f).
[(No — Skip Attachment C.
the 'Permittee own all of the land associated with the wastewater collection, treatment, conveyance, and irrigation system?
DoeQ�Yes — Skip Attachment D.
❑ No — Pursuant to 15A NCAC 02T .01 16(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.
Are t e Permittee's affiliations of record correct? Check affiliations.
Yes — 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)
❑ s — Submit documentation that the compliance schedules have been met.
L� No — Skip Attachment F.
FORM: SFRWWIS-R 02-21 Page 3 of 4