WQ0040799_Application_20230721

DWR
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources
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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.gov/Forms/NonDischarge-Branch-Submittal-
Form-Ver2, or emailed to Non-Discharge.Reports(u)ncdenr.gov if less than 20 megabytes (MB).
SECTION I —APPLICANT INFORMATION
1.
Applicant: Mitchell Johnson and Nicole Johnson
2.
Permit No.: WQ0040799
3.
Signature authority: Mitchell Johnson and Nicole Johnson
Title: Owners
4.
Mailing address: 2617 Whistling Quail Run
City: Apex
State: NC Zip: 27502-
5.
Contact person: Mitchell Johnson
Primary phone number: ( 919 ) 880 - 2692
Email: [e-mail]
Secondary phone number: ( ) -
6.
Secondary Contact person: Nicole Johnson
Primary phone number:( 609 ) 610 - 9777
Email: [e-mail]
Secondary phone number: ( ) -
SECTION II — FACILITY INFORMATION
1. Physical address: 2617 Whistling Quail Run
City: Apex
County: Wake
State: NC
SECTION III — BILLING INFORMATION
1. Billing address: 2617 Whistling Quail Run
City: Apex
State: NC
Zip: 27502-
Zip: 27502-
SECTION IV
— DEED INFORMATION
7Hasa deed been executed and recorded in the County Register of Deeds pursuant to 15A NCAC 02T .0604(e)(1)7 ❑
Yes — Complete Items 1 through 4 below.
❑ No — See Attachment B on Page 3.
1. Parcel No.: 0468889
2. Date of Purchase: September 24, 2020
3. Deed Book: 18091
4. Deed Page Nos.: 513 - 514
FORM: SFRWWIS-CO 03-21 Page 1 of 3

MOM, A7 AM
SECTION
Permit No..0 WQ004079
OPERATION AND MAJINTENANCE
Pet ittee: Mitchell Johnson and Nicoie Johnson(Le, all deed property o%;%rner
County . Wake
The Penn'
tt ads to operate and maintain the single-family residence wastowater treatment and lira abort system
as follows --
I. [aspect the -septic tank annually, aild pump out solids as needed.
. Inspect and clean the septic tank effluent filter annually l if applicable)
3. Inspect the tablet chlorinator %reek 1 . Add wastewater grade chlorine tablets(e,g, calcium h h brie as
heeded. Swimming pool grade c loilne lablets are nor acceptable. (if applicable)
4. Imspect the ultraviolet disinLion unit weekly_ Clean or I-eplace the lamps and quart sleeves as needed. r
applicable)
Inspect all storage tanks* pumps, and alar'nis monthly.
when Pumping the septic tank l ids nut_
Fie move the floaring scum laver in a I l p um plo-stora a tanks
Impect the r i rri a tt n� n� n n h ly to er' f V= proper ration of rthe spray heads: that there at-e no deal •
that vegetative gi-o 'th does not obstruct the spray heads: that the irrigated ante � aler is not po i n l� in or ru nn i n
off the des1gnat irrigation area; and that iher a a"re iia object1anable Gdols - (if applicah le)
7. 1 ns peCt the drip i rri a t on sYstem nio nthlY to verify: proper operation of the dr)"p lines; that there are tic) leaks: that
vegetad a rov�rth does not obstruct the drip emitters-, tot ffie irrigated wastewateris not pondingin or running off'
the deli nar d irrigation area, and that there are no objectionable odors, if opplicable
8. Maintain a sei of. Dik.,isi n-approved engineering plans and specifici
. Pav the mquired annual tee-
10 . Mega St renewal of i h i s r x t on i.� j on -a ppro ed f o •ni s no later than 180 days pilor to expiration.
11. Sign and pmvide a Chan c of Ownership apalicafion to any future owner of the single-family residence
wastewater treatment and irrigation System for their completion and submission to the Division of "later
Resoui-cps.
VWe understand the &ove requirements and agree to these terms as parr of the issued pernidt.
Signature.,
Signature:
Signature:
Signature.
All deeded
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Dare:
Dow
Date
owners shall si it this Operation and Maintenance Aereenient

ATTACHMIENT A — SIGNATURE U T€Iol IT DELEGATION
Does thei?1 gnatli.il a authority in 4o .—,rio � i�.�+v� � +#i h.'.F +1 � n f ■ ■■ rr.�rir�..##+ �7..M-.••� �.h�.# #rti 1 J NCAC 02T.01 06(b )?
L rJ ll .J 1 il*,r�; LJ IXr L U t 460 J J,L..1LLa] *li,a � *UA l� �tj
Yes — Skip Attachment A.
o — Submit a del a gati ors leileiter pursuant to 15 •, NCAC 02T . W 0 auth on zi n g th a signatu re authori ty to si gn
ATTACIEMENT B— PROPERTY OWNLW HI DOCU-M-EWATION
Has a deed been executed and record ed i n the C €aunty Regi ster of Deeds pu rsu an t to 15 A N C Ali 02 T • 0 4 (1)?
e s — C om pl ete Item, s l through 4 i n S ectil on IV on Page l _
FzF i
LN
Submit a written not. d intent to Purchase agreement sign by both parties with a plat or survey map pursuant to 15A
NCAC 0T . } or
ubilui t a wtitten notarized lease agreemeni that specifically indicates the intended use of the property and has been si an d
by both parties, as well as a plat or survey map pursuant to 15A NCAC o T _ 0 0 . Lease agreements shall adhere to
the requirements of 15A NC AC 02L _ 0 107-
CO
APPLICANT'S CERTIFICATION
(Signature authont - s. name as noted in Section I� 1iem -3 )
attest that this applicatiQl
has been reviewed by me and is accurate and complete to the bet of my knowledge, I understand that if all required parts of ` th i s
application package are not completed. and that 'if all required supportIng information and attachments are not included, th i s
appl i ea.t1 on package VVIII be returned as incomplete- I further certify pursuant to 1 A NCAC 0 1" .0120(Ja that the applicant, or
any parent} sub sidi } or other affi 1 i ate of the a applicant has.- not been convicted of environmental crimes under; not previously
abandoned a tewater treatment facility without properly closing the facility- not paid a civill penalty; not been compliant with
any compI r ance s chedul a in a perm it, setdem ent agreement, or order; not paid an annual fee,
Note- The Applicant's Certification shall be signed pursuant to 1 Ai NCAC 02T .01 n altercate perm may be delegated
as the .signing official if a letter is provided pursuant to 15A NCAC o T .. ] c , Pursuant to § 143-215.6A and § 14 - 1 _
anv -Drson who knowingly makes env false statement., representation, Or certi fication in any application package shall be gui 1 ter of a
Class rn i s erner�i c 2r nC 1 a fine t t e c 10, 0 00 as re] ! as ci vil penal b es up to S25,0 00, per vi o1 ate on , y
Signature -
Dam --7IZc� /Z
THE COMPLETED APPLICATION ASID ATTACHMFNTS SUALL BE SUBMITTED AS A SINGLE PDF FILE Ili:
Las erf ch e U plo ad:
l i ii- a ar e.ort err d r�r. o htt ://e(locs.de ■nc, ov/Forms/NonDischar e-Braz,ch-
ubmittal-Form-Vert
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