WQ0004113_Application_20230228

Initial Review
Reviewer
Nathaniel.Thornburg
Is this submittal an application? (Excluding additional information.) *
Yes No
Permit Number (IR) *
WQ0004113
Applicant/Permittee
Triangle Land Conservancy
Applicant/Permittee Address
Post Office Box 1848, Durham, NC 27702
Is the owner in BIMS? Yes No
Is the facility in BIMS? Yes No
Owner Type
Organization
Facility Name
4447 Range Rd. SFR
County
Durham
Fee Category Single -Family Residence
Fee Amount $0
Is this a complete application?*
Complete App Date
Yes No
02/28/2023
Signature Authority
Signature Authority Title
Signature Authority Email
Document Type (if non -application)
Email Notifications
Does this need review by the hydrogeologist? * Yes No
Regional Office
CO Reviewer
Admin Reviewer
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* Kierra Hyman
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*
9842876149
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:*
WQ0004113
Has Current Existing permit number
Applicant/Permittee*
Triangle Land Conservancy
Applicant/Permittee Address*
Post Office Box 1848, Durham, NC 27702
Facility Name*
4447 Range Rd. SFR
Please provide comments/notes on your current submittal below.
Change of Ownership form to change the owner of this permit from Jean G. Morrison to the Triangle Land Conservancy.
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.)
CR address change.pdf 328.99KB
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
A" 4v
Submission Date 2/28/2023

DWR
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources
15A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE
WASTEWATER IRRIGATION SYSTEM — CHANGE OF OWNERSHIP
FORM: SFRWWIS-CO 03-21
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 .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:Hedocs.deci.nc.2ov/Forms/NonDischar2e-Branch-Submittal-
Form-Ver2, or emailed to Non-Dischar2e.Reports(d)ncdenr.2ov if less than 20 megabytes (MB).
SECTION I
— APPLICANT INFORMATION
1.
Applicant: Triangle Land Conservancy
2.
Permit No.: WQ0004113
3.
Signature authority: Kierra Hyman
Title: Program Associate
4.
Mailing address: Post Office Box 1848
City: Durham
State: NC Zip: 27702-
5.
Contact person: Margaret Sands
Primary phone number: [phone] Office
Email: [e-mail]
Secondary phone number: ( ) - Select
6.
Secondary Contact person: Kierra Hyman
Primary phone number: [phone] Select
Email: [e-mail]
Secondary phone number: ( ) - Select
1. Physical address: 4447 Range Rd
City: Rougemont
SECTION II — FACILITY INFORMATION
County: Durham
State: NC Zip: 27581-
SECTION III — BILLING INFORMATION
1. Billing address: Post Office Box 1848
City: Durham State: NC Zip: 27702-
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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.
1 1. Parcel No.: 192121 12. Date of Purchase: July 28, 2021 1
3. Deed Book: 009410 14. Deed Page Nos.: 39 - 42
FORM: SFRWWIS-CO 03-21 Page 1 of 3

SECTION V — OPERATION AND MAINTENANCE AGREEMENT
Permit No.: WQ0004113 County: Durham
Permittee: Triangle Land Conservancy (i.e., all deeded property owners)
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. (ifapplicable)
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 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:
Signature:
Signature:
Signature:
Date: 02/28/2023
Date:
Date:
Date:
All deeded property owners shall sign this Operation and Maintenance Agreement
FORM: SFRWWIS-CO 03-21 Page 2 of 3

ATTACHMENT A— SIGNATURE AUTHORITY DELEGATION
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.
ATTACHMENT B — PROPERTY OWNERSHIP DOCUMENTATION
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 15A NCAC 02T .0604(e)(3). Lease agreements shall adhere to the
requirements of 15A NCAC 02L .0107.
APPLICANT'S CERTIFICATION
I, /lam Y 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 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: 02/28/2023
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Email:
Non-Dischar2e.Repo rts(& nc denr.2ov
Laserfiche Upload:
http s:Hedo c s. de q. nc. uov/Forms/NonDischarue-Bra nch-
Submittal-Form-Ver2
FORM: SFRWWIS-CO 03-21 Page 3 of 3