WQ0011761_Application_20231009

I?WR
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources
15A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE
WASTEWATER IRRIGATION SYSTEM — RENEWAL
FORM: SFRWWIS-R 02-21
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 .01009 15A NCAC 02T .0600, and Di+. ision PoUcies. 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:lledoes.de(l.ne.2ov/Forms/NoiiDiseliaree-Branch-Subnritial-
Forni-X'er2, or emailed to Non-Diseharge.Reports(r ncdenr. ov if less than 20 megahytes (MR).
SECTIO
I — APPLICANT INFORMATION
1.
Applicant: David B. Caudle
2.
Permit No.: WQ0011761
3.
Signature authority: David B. Caudle
Title: Owner
4.
Mailing address: 134 Gold Meadow Dr.
City: Cary
State: NC Zip: 27513-
5.
Contact person: David B. Caudle
Email: [e-mail]
Primary phone number: [phone] Office
Secondary phone number: ( ) - Select
6.
Secondary Contact person.
Email:
Primary phone number: ( } - Select
Secondary phone number: ( } - Select
SECTION; II — FACILITY INFORMATION
1. Physical address: Parcel No. 69677 County: Chatham
City: Apex State: NC Zip: 27502-
SECTIOjq 11I — BILLING INFORMATION
). Billing address: 134 Gold Meadow Rd.
City: Cary
2. Verify the Applicant does not have any overdue annual fees:
State: NC Zip: 275134926
https:)'ideq.nc.goviabout/divisions/water-resourcca water-resourcespennits rvq-e-epayments
Pursuant to 15A NCAC 021' .0120(c), permits far renewing facilities shall not be granted if the Applicant or any affiliation has
an unpaid annual fee.
FORM: SFRWWIS-R 02-21 Pagel of4

SECTION IV — OPERA FION AID MAINTENANCE AGREEMENT
Permit No.: WQOO11761
Permittee: David B_ Caudle (i.e., all deeded property owners)
County: Chatham
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 3ut solid 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 rot acceptable. (if'applicahle)
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 emitter,; that the irrigated wastewater is not ponding in or running off
the designated irrigation area; and that them 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 aI� 1p icatio i to any 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 a uirem d agree to these terms as part of the issued permit.
Signature: Date: J 5 f Z y
Signature: Date:
Signature:
Signature:
Date:
Date:
All deeded property owners shall sign this Operation and Maintenance Agreement
FORM: SFRWWIS-R 02-21 Page 2 of

ATTACHMENT A - SITE MAP
Was the facility originally permitted or had a major modifcatio t 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 map of the site with topographic contour intern als 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 iurface dridnage features within 500 feet of all wastewater treatment, storage.
and irrigation sites.
❑ Delineation of the compliance and review boundaries X er 15A NCAC 02L .0107 and .0108, and 15A NCAC 027- .0601.
❑ Setbacks as required by 15A NCAC 02T ,06W
❑ Site property houndaries within 500 feet of all wastewater treatment, storage, and irrigation sites.
❑ All habitable residences or places of public cssembly within 500 feet of all treatment, storage, and irrigation sites.
❑ No - Skip Attachment A.
ATTACHMENT B- SIGNATIJRE AUTHORITY DELEGATION
Does the signature authority in Section I. Item 3 nice. the requirements pursuant to 15A NCAC 02 1 .0106(b ?
❑ Yes - Skip Attachment B.
❑ No - Submit a delegation letter pursuant to 15A 24CAC 021 .01, 06(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, .is 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 provi& a reevaluation of the reduced flow value pursuant to the requirements in 15A
NCAC 02T .0114W.
❑ No - Skip Attachment C.
ATTACHMENT D - EASEMENT, ENC16ACHMENT, AND LEASE AGREEMENTS
Does the Permittee own all of the land associated with the wastewater collection, treatment, conveyance, and irrigation system?
❑ Yes - Skip Attachment D.
❑ No - Pursuant to 15.A NCAC 021 .01 16(c), provide a copy of all easements, lease agreements, and encroachment agreements
allowing the Permittee to operate and maintain the wast.•nvater collection, treatment, conveyance, and irrigation system on
property not owned by the Pennittee.
ATT ::HMEN1 E - AFFILIATIONS
Are the Permittee's affiliations of record correct? Check atlili4tion.".
❑ Yes - Skip Attachment E.
❑ No - Provide the corrected affiliations and their �,ontact information.
ATTAC NT F - C+ MPLIANCE SCHEDULES
Does the existing permit include any Compliance Schedules? (ke Section I of the most recently issued permit)
❑ Yes - Submit documentation that the complianec schedules have been met.
❑ No - Skip Attachment F.
FORM: SFRWWIS-R 02-21 Page 3 of

ATTACHMENT G — CIVH� PENALT*S AND OUTSTANDING VIOLATIONS
Does the Pennittee have any existing civil penalties c.r outstanding violations'?
❑ Yes (civil penalties) — Submit payment for the civil penalty, or proof of remission request.
❑ Yes (violations) — Submit a copy of your respon.e to the Notice of Violation.
❑ No — Skip Attachment G.
ATTAC4.%IENT H SETBACK WAIVERS
Does the existing permit include setback waivers?
❑ Yes — Pursuant to 15A NCAC 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 15A NCAC 02L .0107.
❑ No — Skip Attachment H.
/ ]' APPLICANT'S CERTIFICATION I
attest that this application
( i5 gnature authority's name us noted in Section 1, Item 3)
has been reviewed by me and is accurate and complete to the Kest of my knowledge. I understand that if all required parts of this
application package are not completed, and that if all requited supporting information and attachments are not included, this
application package will be returned as incomplete. l further certify pursuant to 15A NCAC 02T _0120Ib1, that the applicant, or any
parent, subsidiary, or other affiliate of the applicant hits: 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 15A NCAC 02T .0106i b1. An alternate person may be delegated as
the signing official if a letter is provide pursuant tc, 15A NCf.0 02T .0106 c . Pursuant to § 143-215.6A and § 143-215.6B, any
person who knowingly kes any f tement, representatio,i, or certification in any application package shall be guilty of a Gass
2 misdemeanor, whi in nc a not to exceed $10,001 as well as civil penalties up to $25,000 per violation.
Signature: (`� :' S Date:
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL DE SUBMITTED AS A SINGLE PDF FILE VIA:
Email:
Non- Discharze.Reports(d ncdenr.eo%
Laserfiche Upload:
httas.11edocs.deu.tic.eur [Forms[NonDischaree-Branch-
Submittal-Form-Ver2
FORM: SFRWWIS-R 02-21 Page 4 of 4