WQ0003269_Application_20230224

Initial Review
Reviewer Nathaniel.Thornburg
Is this submittal an application? (Excluding additional information.) *
Yes No
Permit Number (IR) * WQ0003269
Applicant/Permittee Michael Delos Santos
Applicant/Permittee Address 782 Stoney Mountain Rd, Burlington, NC 27217
Is the owner in BIMS? Yes No Is the facility in BIMS? Yes No
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
782 Stoney Mountain Rd SFR
Alamance
Does this need review by the hydrogeologist? * Yes No
Regional Office
CO Reviewer
Admin Reviewer
Fee Amount
Complete App Date
02/24/2023
$0
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* Michael Delos Santos
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*
919-888-8138
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.
https://edoes.deq.nc.gov/Forms/NonDischarge_Monitoring_Report
Permit Type:*
Wastewater Irrigation
High -Rate Infiltration
Other Wastewater
Reclaimed Water
Closed -Loop Recycle
Residuals
Single -Family Residence Wastewater
Other
Irrigation
Permit Number:*
WQ0003269
Has Current Existing permit number
Applicant/Permittee*
Michael Delos Santos
Applicant/Permittee Address*
782 Stoney Mountain Rd, Burlington, NC 27217
Facility Name*
782 Stoney Mountain 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.)
WQ0003269_Change Of Ownership
1.11 MB
(Sig ned)_20230224.pdf
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 2/24/2023

?M a- a a 2 3 State of North Carolina
NC Depart ni
Environmental (. Department of Environmental Quality
00- Receive,! Division of Water Resources
wool
Division of Water Resources FEB 2 4 2Krl 15A NCAC 02T .0600 - SINGLE-FAMILY RESIDENCE
WASTEWATER IRRIGATION SYSTEM - CHANGE OF OWNERSHIP
Winstor: FORM: SFRWWIS-CO 03-21
egion .'
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 .01009 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 https://edoes.deg.nc.gov[Forms[NonDischari!e-Branch-Submittal-
Form-Vert, or emailed to Non-Discharge.Reports(a)ncdenr.gov if less than 20 megabytes (MB).
1. Applicant: Nicolas de los Santos, Elida de los Santos, and Michael de los Santos
2. Permit No.: WQ003269
3. Signature authority:
Title: O W(v—.e—
4. Mailing address: `)67, S40" rV10 ,'0*je` �Z,a
City: oU `4 �pr�
State: Zip: f ?
5. Contact person: rnpC�nr [" S S�,n -F o5
Primary phone number: VTSelect
Email: �'1 QCh01,e (, 0e.[o3 ,,3,:�, n4C1 Z )3c,) y q hg6,
Secondary phone number: ( ) - Select
6. Secondary Contact person:
Primary phone number: ( ) - Select
Email:
Secondary phone number: ( ) - Select
1. Physical address: %$ Z JV�" Movr1+o- ^ rL i County: q I A W 01h 6L
City: D U j ff(cK \ State: NC Zip: 7 "7-6 I ')�
Has a deed been executed and recorded in the County Register of Deeds pursuant to 15A NCAC 02T .0604(e)(1)?
® Yes - Complete Items 1 through 4 below.
❑ No - See Attachment B on Page 3.
:C'k-Xj
I. 1:. Parcel No.: 1561.23 1.2. Date of Purchase: August 17, 2022 1
13. Deed Book: 431 14. Deed Page Nos.: 273 -
FORM: SFRWWIS-CO 03-21 Page 1 of 3

County: Alamance
Permittee: Nicolas de los Santos, Elida de los Santos, and Michael de los Santos (i.e., all deeded property owners)
The Permittee agrees to operate and maintain the single-family residence wastewater treatment and irrigation system as
follows:
Inspect the septic tank annually, and pump out solids as needed.
Inspect and clean the septic tank effluent filter annually. (if applicable)
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)
Inspect the ultraviolet disinfection unit weekly. Clean or replace the lamps and quartz sleeves as needed. (if
applicable)
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.
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)
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)
Maintain a set of Division -approved engineering plans and specifications.
Pay the required annual fee.
Request renewal of this permit on Division -approved forms no later than 180 days prior to expiration.
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.
I Ii_-2-3
All deeded property owners shall sign this Operation and Maintenance Agreement
FORM: SFRWWIS-CO 03-21
Page 2 of 3

Does the signature authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)?
® 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)?
® Yes — 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 I5A NCAC 02T .0604(e)(3). Lease agreements shall adhere to the
requirements of 15A NCAC 02L .0107.
attest 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 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 .0106(c). Pursuant to § 143-215.6A and § 143-215.6B, any
person who knowingly makes anyfalse statement, representation, or certification in any application package shall be guilty of a Class
2 misdemeanor, which ma ' ude 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: Laserfiche Upload:
Non- Disc harge.Reports(izncdenr.gov https://edoes.deg.nc.2ov/Forms/NonDischar2e-Branch-
Submittal-Form-Ver2
FORM: SFRWWIS-CO 03-21 Page 3 of 3