WQ0019188_Application_20230501

State of North Carolina
DWR
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:Hedoes.deg.nc.gov/Forms/NonDischarge-
Branch-Submittal-Form-Vert,or emailed to Non-Discharge.Reportsna,ncdenr.gov if less than 20 megabytes(M B).
SECTION I—APPLICANT INFORMATION
1. Applicant:Pamela Iacovelli and Joel Iacovelli
2. Permit No.:WQ0019188
3. Signature authority:Pamela Iacovelli and Joel Iacovelli Title:Owners
4. Mailing address:
City: State: Zip: -
5. Contact person:Pamela Iacovelli Email:[e-mail]
Primary phone number.( ) - Select Secondary phone number:( ) - Select
6. Secondary Contact person:Joel Iacovelli Email:
Primary phone number:( ) - Select Secondary phone number:( ) - Select
SECTION❑—FACILITY INFORMATION
1. Physical address: 118 Gold Finch Ln. County: Chatham
City:Apex State:NC Zip:27523-
SECTION III—BILLING INFORMATION
1. Billing address:
City: State: Zip: -
SECTION IV—DEED INFORMATION
Hasa deed been executed and recorded in the County Register of Deeds pursuant to 15A NCAC 02T.0604(e)(1)?❑
®EI Yes—Complete Items 1 through 4 below.
❑No—See Attachment B on Page 3.
1. Parcel No.:0076937 2. Date of Purchase:November 23,2022
3. Deed Book:2337 4. Deed Page Nos.:746-747
FORM:SFRWWIS-CO 03-21 Pagel of3

SECTION V—OPERATION AND MAINTENANCE AGREEMENT
Permit No.: WQ0019188 County: Chatham
Permittee: Pamela Iacovelli and Joel Iacovelli(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.(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.
11. Sign and provide a Change of Ownership application to any future owner of the single-family residence
wastewater treatment an gation system for their completion and submission to the Division of Water
Resources.
I/We unders abov equirements and agree to these terms as part of the issued permit.
Signature: Date:
Signature: Date: k4 a2q ..02 3
Signature: Date:
Signature: 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 1,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
21! c,p V 1L� attest that this application
(Signature authority's name as noted in Section 1,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 Ap is Certification shall be signed pursuant to 15A NCAC 02T.010 n alternate 6(b). An person may be delegated
as the signin office 1 if a letter is provided pursuant to 15A NCAC 02T .0106(c). Pursuant to § 143-215.6A and § 143-215.6B,
any person ho kn ingly makes any false statement,representation,or certification in any application package shall be guilty of a
Class 2 mi erne r which may include a not to exceed$ 000 as well civil penaltie up t;o
$25,000 per violation.
JSignature. Date: —
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email: Laserfiche Upload:
https://edoes.deg.ne.gov/Forms/NonDischarge-Branch-
Non-Discharge.Reports(a�ncdenr.gov Submittal-Form-Vert
i
FORM: SFRWWIS-CO 03-21 Page 3 of 3