WQ0037500_Application_20230605

State of North C'at-(ditia
Dep.artincrit of Environmental Quialliv
4
D19visioll Of Water Rcsotii"ces
Division of Water Resources t �f1 i�I[-'.�[� 02T .I 600 — SI NG L[I"-1" A ""N111,Y RFSI D LM -1..
NVAS'FFOWA'1 14:1z 114141t ri ,\ Sti1,1%sTEM — C"ANGE OF OWNERSHIP
1- ()RM *, SFRWNVIS-00 03-2l
Pursuant to 15A NCAC 02T.010 if the application does not includeall rLy!sirr(l infurrnt.itiun and the necessary supporting
documentation,, the application shall be returned. The application and attaclirnents shall be prepared in accordance with I SA
NCAC 02T .0100, 15A NCAC 02T .0600, and Division Policies. ��ur inure information, visit the Water Quality Permitting
Section's Non -Discharge I3r�inch �vchsite. The Applicant shall submit ��n cicctronic copy of the a���licatic�n and attachmcntS
uploaded as a single Portable Document Format (PDF) tilt to litti)so//edocs.(Ie(l.nL.gov/ oritis/NoiiDisclietir(yc-[3ranch-Stfbmitttil-
Form-Ver2,or cmailed to Non-Discharoe.11epor ncdenr.gov if less than 20 megabytes (MB).
SECTION
1. Applicant- i'ranay Parekh and Chhaya Parekh
12. Permit No.; WQ0037500
I — APPLICANT INFORMATION
3. Signature authority: Pranay Parekh and Chhaya Parekh Title: Owners
4. Mailing address: ? 13 Slate Blue Place
City: Cary State: NC Zip: 27519-
5. Contact person: Pranay Parekh Email: 1
200P(cell/home/etc)Primary phone number: �,�57 7 (work/ ell ome) Secondary phone number: ( ) -
6. Secondary Contact person: Chhaya Parekh Email:
Primary phone number: ((t1)157-7o�awork/fe_ home) Secondary phone number: ( ) - (cellihome/etc)
SECTION II —FACILITY INFORMATION
Physical address: .2118 Carolina Crossings Dr. County: Chathani
City: Apex State: NC
SECTION III —BILLING INFORMATION
1. Billing address: � �3 ,rj LATE' L�l,a� PL
Ciq:
State: !"JC-
SECTION IV —DEED INFnRMATION
Zip
zic�
Has a deed been executed and recorded in the County Register of Deeds pursuant to 1 SA NCAC 02T .0604(e)(1)?
j� Yes — Complete Items 1 through 4 below.
❑ No —See Attachment B on Page 3.
1. Parcel No.: 0090787 2. Date of Purchase: Jung 25, 202ma I
;. Deed Book: 2226 4. Deed Page Nos.: 7 11 - 712.&
FORM: SFRWWIS-CO 03-21
Page 1 of 3

SECTION V — (VERATION AND MAINTENANCE AGREEMENT
Permit No.: WQ0037500
Permittee: Pranay Parekh and Chhaya Parekh (i.c.. III (lceded property owners)
4
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County: Chatham
Tile Permittee agrees to operate and maintain the sirlOc-family residence wastewater treatment and irrigation system as
follows:
I - Inslicct the septic tank annually, and pump out solids as needed.
2. Inspect and clean the septic tank effluent filter annually. Qfapplicablc)
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 al.lrms monthly. Remove the: floatino scum layer in all pump/storage tanks
when pumping the septic tan{: 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 poiidin(,-,y in or running
off the designated irrigation area; and that there arc no objectionable odors. (if aj)plicable)
7. Inspect the drip irrigation system monthly to verity: proper operation of the drip lines; that there are no lcc"Iks; that
vegetative growth does not obstruct the drip emitters; that the irrigated wastewater is not ponding in or running off
the designated irri,atipon area; and that there are no objectionable odors. Qfapplicable)
8. N/laintain a set of Division -approved engineering plans and spcci1 icatiOils.
9. Pay the required annual fee.
10. Request renewal of this pe mi i t on nip isio»-approved forms no later than 180 days prior to expiration.
11. Sign and proN,Ide a Change of Ownership application to a�iy 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: C.
Signature:
Signature:
A l ! r f eptI t'd
FORM: SFIZWWIS-CO 03-21
ro i) a rt
Date:
Date:
0i'vea-
Date:
o V--0�7, I ffi)� 23
t11%Vf1V10q Sjj,jjj sioll this �)��ci%itio n and NLihiten-mice Aureement
11,t,ge 20 of 3
A

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ATTACHMENT A — SIGNATURE AUTHORITY DELEGATION
Does the signature authority in Section 1, Item 3 meet the requirements pursuant to 15A NCAC 021 .0106(b)?
Z Yes — Skip Attachment A.
❑ No — Submit a delegation letter pursuant to 15n 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(n(I )?
� Yes — Complete Items l through 4 in Section IV on Page I .
❑ 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 cif the property and has been signed by
both parties, as well as a plat or survey map pursti-ant to 15A NCAC 02"1 .0604(e)(3). Lease agreements shall adhere to the
requirements of 15A NCAC 02L .0107.
APPLICANT'S CERTIFICATION
� 1,r\,*-f%j 11sq P,-VA .QP096N.S:jd attest that this application
(Signature authuritN 's name as noted in Section 1, Item 3)
01
has been reviewed by me and is accurate inci 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 nit included, this
application packac-ye will be returned as incomplete. I further certify pursuant to 15A NCAC 02T .0120(b), that the applicant, or and
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 clo5in� the facility; not paid a civil penalty; not been compliant \ti ith 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 021- .01OG(b). An alternate person ma} be delegated as
the signing official if a letter is provided pursuant to 15A NCAC 02'17 .0 l Q_0(c I'w-suant to § 143-215.6A and ti I43-215.6B, any
person who knoxvingly makes any false statement, representation, or certit ication in any application package shall be guilty of a Class
2 misdemeanor, which may include a fine not to exceed S 10.,0 00 as well as civil penalties up to S2>,000 p er violation.
Signature:
7 n-� �c��� p C • 1� Ta�� . Date. -
THE COMPLETED APPLICATION AND ATTACHMENTS S 11 k LL BE SU BIM II'T r D AS A SINGLE PD F FILE VIA:
F, III a i 1:
N on- Disctiarze.RenortS a,ncc]enr.��ti
Laserfiche Upload:
lit N:,//e oCS-ale .roc goV/Fornis/NonDischaroe-M%Jtich-
ubni itrtfl-Form-krer?
FORM: SFRWWIS-CO 03-21
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