WQ0006897_Application_20230315

State of North Carolina
Department of Environmental Quality
w;:• Division of Water Resources
1)Mslon of Water Resources 15A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE
WASTEWATER IRRIGATION SYSTEM —CHANGE OF OWNERSHIP
FORM: SkRWWIS-CO 03-21
Pursuant to 15A NCAC 02T _01117 if the application does not include all required information and the necessary
supporting documentation, the application shall he 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 h s:lledocs-de .tic. ov/Forms/Noi Dischar e-
Branch-Submittal-Form-Vert, or emailed to Non-Dischar e.Re orts a ncdenr. ov it lessi than 20 megabytes (MS).
1 • Applicant: HaIAUt 'IT S EA
2. Permit No.: WQo4 0 L PI-7
3. Signature authority:
4. Mailing address:
City: j Z 1 kuvrphy Sabi, I
S. Contact person: Tot 5
Primary phone number: Ml1 7,;`�ect toi
6. Secondary Contact person:
Primary phone number: A q rJ T?-N elect rj- j i
.11-�- �1D5. , I(Aa
Title:
Stale: PW] , dip= Z770�
Email: kja a{iy bD h5C96mof j . (-6M
Secondary phone number: (go-s2-1412ct p-
Email:. r-,ar iQSd� 7slGt r1. Cem
Secondary phone number; ( } - Select
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,r;�a,r: ;, ...e::sy�:r:::_:.-
1. Billing address: 41 ?4 pgu-.Y `f �i< l,YI, a t i4f. . —. _.
II�
City: State: AIL Ltp: 7 7C6r.J
Has a deed been execuled and recorded in the County Register of Deeds pursuant to I SA NCAC 02T .0604(e)(1 j.?
20 Yes — Complete: Items 1 through 4 below.
❑ No — See Attachment B on Page 3.
1- Parcel No.: V. gq"'M 6
3. Deed Book: (PSo c5 ^
2. Date of Purchase: l _ Gq _ Z023
4, Deed Page Nros.: - j ❑
FORM: SFRWWIS-CO 03-21 Page I of 3

The Permittee agrees to operate and maintain the single-family residence wastewater treatment and irrigation systcm
as follows:
1. Inspect the septic tank annually, and ptunp 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 applicuble)
4. Inspect the ultraviolet disinfection unit weekly. Clean or replace the lamps and quartz sleeves as needed. Qf
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 pond ing in or
running off the designated irrigation area; and that there are no objectionable odors. Qf 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 irrigations area; and that there are no objectionable odors. QJ'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 190 days prior to expiration.
11. Sign and provide a Chan e of Ownership application to any future owner of the single-family residencc
wastewater treatment and irrigation system for their completion and submission to the Division of Water
Resources.
IIWe understand the above requirements and agree to these terms as part of the issued permit.
Signature:
Signature:
Signature:
Signature;
FORM: SFRAVIS-CO 03-21 Page 2 of

........................--...................,............:..............................-- ......
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..:::::.:....::...siTT4C T::B:t'I[]PERTY'f344`NERSHiP:AUC[1ALFN';Tii►IO.::::::::::.,
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Has a deed been executed and recorded in the County Register of Deeds pursuant to 15A NCAC 02T .0604(f)(1)? ❑
R❑ 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.
" attest that this application
(Signature authority's name as noted in Section I, item 3)
has been rm'iewed by me and is accurate and complete to the best of nay 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 , 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 CertiFcation 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 § 143-21.5.613,
any person who knowingly snakes 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. I
Signature. -
Date:
THE COMPLETED APPLICATION AND ATTACILUfENTS SHALL BE SUBMITTED AS A SINGLE PDF FILL VIA:
Email:
Non-Discha e.Re orts o.ncdenr. ov
Laserfiche Upload;
htt s:lledocs.de .ne. ov/Forms/NanDischar e-Branch-
S u hmittal-Furni-V er2
FORM: SFRWWIS-CO 03-21 Page 3 of 3