WQ0022017_Application_20230221

State of North Carolina
Department of Environmental Quality
Division of Water Resources
DMAon of Water Resources 15A NCAC 02T .0600—SINGLE-FAMILY RESIDENCE
WASTEWATER IRRIGATION SYSTEM —CHANGE OF OWNERSHIP
FORM: SFRWWIS-CO03-21
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 .060Q, 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 hups:lledocs.deq.ne.gov/Forms/NonDisc_ha r2e-Branch-Submittal-
Form-Ver2, or emailed to Non-Dischar¢e.ReaortsC�ncdenr.eov if less than 20 megabytes (MB).
1. Applicant:
2. Permit No.: WQ00
3. Signature authority: Title: �v
4, Mailing address: 9 5 I Z wCi-,lALAA -i r-DJ8 Oh rr ckt $24
City: State: 0 C, Zi
5. Contact person: -D" Rtj _31r4C.l-.bt -r& —11 Email: da". blac <-bL.trr- (DJ WL caw1
Primary phone number: ((j 11)66o- 641elect C-CAJ Secondary phone number: (jlcl )a%- I L24Select
6. Secondary Contact person: '3ohbLi 'D";,s
Primary phone number: (g�
Emai l: k}dJ rs cpt-iC. 06 rfzc" l • C.Q nn,
Secondary phone number: ( ) - Select
71
CTION III —BILLING INFORMA
I. Billing address: q ►7 hJaA n of 14nxc, Ckurch Pc
City: �-Lrj fe, M r ilS State: �jG Zip: a*
Has a deed been executed and recorded in the County Register of Deeds pursuant to 15A NCAC 02T .0504(e)(1)?
?� es — Complete Items 1 through 4 below.
❑ No — See Attachment B on Page 3.
1. Parcel No.:
2. Date of Purchase: 91 a7
3. Deed Book: a3 Of 1 4. Deed Page Nos.: 3(o'] -
FORM: SFRWWIS-CO 03-21 Page i of 3

SECTION V - OPERATION AND MAINTENANCE AGREEMENT _
Permit No.: WQOO a� aU `� County:
or&,-'3c
Permittee: (i.e., all deeded property owners) ny ,1 � � t S+Y"Ie,N m ol�l �j�hn8w3
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 pond ing 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.
1 I . 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: 9.111nl a
Signature: �'�' 4��' Date: -a
Signature:
Signature:
Date:
Date:
All deeded ❑roperty o►%ner_s shall sign this Operation and Maintenance Agreement
FORM: SFRWWIS-CO 43-21 Page 2 of

ATTACHMENT A —
TIO.N
Does the signature authority in Section 1, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)2
❑ Yes — Skip Attachment A.
❑ No —Submit a delegation letter pursuant to 15A NCAC 02T .0106(c} authorizing the signature authority to sign.
Has a deed been executed and recorded in the County Register of Deeds pursuant to 15A NCAC 02T .0604(f)(1)`'
�'es — Complete Items 1 through 4 in Section IV on Page 1,
❑ No
❑ Submit a written notarized intent to purchase agreement sign by both parties with a plat or survey map pursuant to 15A NCAC
02T .0604(e)(2); or
❑ Submit a written notarized lease agreement that specifically indicates the intended use of the property and has been signed by
both parties, as well as a plat or survey map pursuant to 15A NCAC 02T .0604(e)(3 . Lease agreements shall adhere to the
requirements of 15A NCAC 02L .0I07.
st 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(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 property 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.0106(c). Pursuant to § 143-215.6A and § 143-215.613, 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 AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email-
Non-Disch_a rize. Reports(o)ncden r.gflW
Laserfiche Upload:
htt s://edocs.de .ne. ov/Forms[NonDischar e-Branch-
Submittal-Form-Vert
FORM: SFRWWIS-CO 03-21 page 3 of 3

.. .
ROY COOPER
�
i;aL'rrl❑7
1'
ELIZABETH S. BISER`
Jot:'I etta L'
'glyyAvf�
S. DANIEL SMITH
NORTH CAROLINA
DivecFor
Environmental Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCOO 1 1 1 1
1. Facility Name:
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
_za. Change its ownership of property/company
b. Name change only
c. Other (please explain):
2. New owner's name (name to be put on permit):
o r N C G
L,(rv1
3. New owner's or signing official's name and title: rVu
Person legally responsible for permit)
(Title)
4, Mailing address: 95n J 10 uk 6 Q V& (,h umkPAC ity: " rd le 6 06
State: Zip Code: 2T541 Phone: ( 9 t q ) - 52o B
E-mail a
tt U v nna_; 1.
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
[see reverse side of this page for signature requirements]
-� worth Carolina Department of Environmental Quality I Divialnn of Water Re -sources,
SI-r North Sal isbu v Str£ei 11b17 M1aif Service Center Ueigh. North C:arollna 27b94 IG17
90.7079000
r�

NPDES Name & Ownership Change
Page 2 of 2
Applicant's Certification:
n attest that this application for a
namelo ership change has been reviewed and is accurate and complete to the best of my
knowledge. I understand that if all required parts of this application are not completed and that
if all required supporting information and attachments are not included, this application
package will be returned as incomplete.
Signature: Date: o?-
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ ! DWR 1 NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
Version 712016