WQ0006819_Application_20230425

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SECTION I1— FACILITY INFORMATION
I. Physical address. 6346 Stoney Mountain Rd County: Alamance
City: Burlington State: NC Zip: 27217- w
l SECTION III —BILLING INFORMATION I
1. Billing address, 6346 Stoney Mountain Rd
City: Burlington State: NC Zip: 27217-
2, Verify the Applicant does not have any overdue annual fees:
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Pursuant to , permits for renewing facilities shall not be granted if the Applicant or any affiliation has
an unpaid annual fee,
FORM: SFkW WI5-R 42-21
Page I of 4
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SECTION r%'— OPER.ATiON A�'D .%iAL%TE_,NAN-CE AGREEMENT
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Prrrainzc: Rcb-rt E. zmd Billie N1_ Bo, -well (i.e_. all dt�_-ded Fropem' owners)
TI:a Ptrmitx-- agrees to opera*m and maintain Lhe single-fasnily residence wastewater treatment and irrigation s)'qem as
follcr-a s:
I . Inspect the s:Ytic tank annuaIh-, and pump oirt solids as needed_
2. Inspect and clmn the septic tank effluent filter annually- (if applicable)
3. Inspect the tablet chlorinator weekly. Add wastewater grade chlorine tablets (e.g., calcium h}pochlorite) as needed_
Skimming pool grade chlorine tablets are not acceptable. (fapplicable)
A. Inspren the Ultraviolet disinfection unit weekh% Clean or replace the lamps and quartz sleeves as needed. (if
applicable)
5. Inspect all storage tans, pumps, and alarms monthly. Remove the floating scum kyer in all pump/storage tanks
when pumping the septic tank solids out.
Fi. 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 irrigatedwastewater is not ponding in or running
off the designated irrigation area; and that there are no objectionable odors. (ifapplicable)
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.
f
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 oFOwnership application to any future owner of the single-family residence w•astew-ater
treatment and irrigation system for their completion and submission to the Division of Water Resources.
L/We understand the above requirements and agree to these terms as part of the issued permit.
Signature: i . Y) a Date:
Signature: >
Date:
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Signature: Date:
Signature: Date:
All deeded property owners shall sign this Operation and Maintenance Aesreement
FORM: SFR W Wi5-X 02-21 Page 2 of 4
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f ATTACHMENT G — CIVIL, PENALTIES AND OUTSTANDING VIOLATIONS I I
Does the Penniittee 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.
® No — Skip Attachment G.
ATTACHMENT H --SETBACK WAIVERS I
Does the existing permit include setback waivers?
❑ Yes — Pursuant to 156_NCA 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
with UA NCAC 021..0107.
® No — Skip Attachment H.
APPLICANT'S CERTIFICATION
I, 6 C. S to., 5 c 1 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 .D I 20 , 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 I. A NQAQ 02T_,O106(b). An alternate person may be delegated as
the signing official if a fetter is provided pursuant to 15A N AC 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 exceW 10,000 as well as civil penalties up to $25,000 per violation.
Signature: 9 - & Date; _ 4/P 4,0/ 2.3
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email:
Non-❑ischnrye. Reports a ncdenr.env
Laserfiche Upload:
htt s:l edocs.de .nc. ov/FormstNonDischa e-Brnneh-
Submittal-Form-Vert
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ATTACHMENT A —SITE MAP I
as the facility originally permitted or had a major modification issued after September 1, 2006?
} Yes— Pursuant to 15A NCAC 02T .0105 d , submit a site map pursuant to the requirements in 15A NCAC 02T ,0604(d). These
requirements are.
❑ A scaled trap 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.
ATTACHMENT B — SIGNATURE AUTHORITY DELEGATION
Toes the signature authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T ,Q106 ?
Yes — Skip Attachment B.
] No— Submit a delegation letter pursuant to 15A NCAC 02T .0106(c) authorizing the signature authority to sign.
ATTACHMENT C — FLOW REDUCTION
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 .01 lam.
® No — Skip Attachment C.
ATTACHMENT D — EASEMENT, ENCROACHMENT, AND LEASE AGREEMENTS
Does the Permittee own all of the land associated with the wastewater collection, treatment, conveyance, and irrigation system?
21 Yes— Skip Attachment D.
❑ No — Pursuant to 3 5A NCAC 02T .0116(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,
ATTACHMENT E — AFFILIATIONS
Are the Pcrrnittec's affiliations of record correct? Check affiliations.
Yes — Skip Attachment E,
❑ No — Provide the corrected affiliations and their contact information.
ATTACHMENT F— COM-pLIANCE SCHEDULES
Does the existing permit include any Compliance Schedules? (See Section I of the most recently issued permit)
❑ Yes -- Submit documentation that the compliance schedules have been met.
No — Skip Attachment F.
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