WQ0003202_Application_20231011

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Division of Water Resources 15A NCAC 02T .0600 — SINGLE-FAMIL
WASTEWATER IRRIGATION SYSTEI
FORM: SFf
Pursuant to 15A NCAC 02T .0107{b), if the application does not include all required information and the neces
documentation, the application shall be returned. The application and attachments shall be prepared in actor
NCAC 02T .0100, 15A NCAC 02T .0600, and Division Policies. For more information, visit the Water Qu
Section's Non -Discharge Branch website. The Applicant shall submit an electronic copy of the application s
uploaded as a single Portable Document Format (PDF) file to https://edocs.dea.nc.gov/Forms/NonDischarge-Br.
Form-Ver2, or emailed to Non-Dischar e.Re orts(a-)ncdenr. ov if less than 20 megabytes (MB).
SECTION I — APPLICANT INFORMATION
1. Applicant: John B. Bender
2. Permit No.: WQ0003202
3. Signature authority: John B. Bender Title: Owner
4. Mailing address: 1049 King Dr.
City: Butner State: NC Zip: 27509-
5. Contact person: John B. Bender Email: [e-mail]
Primary phone number: [phone] Home Secondary phone number: (919) 612- fed
6. Secondary Contact person: vicki bender Email: [e-mail]
Primary phone number: [phone] Cell Secondary phone number:
1. Physical address: 1049 King Dr.
City: Butner
SECTION II — FACILITY INFORMATION
County: Granville
State: NC Zip: 27509-
SECTION III — BILLING INFORMATION
1. Billing address: 1049 King Dr.
i City: Butner State: NC
2. Verify the Applicant does not have any overdue annual fees:
Zip: 27509-
htts://de .nc. ■ovlaboutldivisionslwater-resources/water-resources- ertnits/w -e avments
Pursuant to 15A NCAC 02T .0120(c), permits for renewing facilities shall not be granted if the Applicant or an3
an unpaid annual fee.
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NCDF-QID R
C (� k,1~ T 2023
Non-Discharge
Permitting Unit

WQ0003202
County: Granville
)hn B. Bender (i.e., all deeded property owners)
;e agrees to operate and maintain the single-family residence wastewater treatment and irrigation system as
he septic tank annually, and pump out solids as needed.
ind clean the septic tank effluent filter annually. (if applicable)
he tablet chlorinator weekly. Add wastewater grade chlorine tablets (e.g., calcium hypochlorite) as needed.
ng pool grade chlorine tablets are not acceptable. (if applicable)
the ultraviolet disinfection unit weekly. Clean or replace the lamps and quartz sleeves as needed. (if
ale)
ill storage tanks, pumps, and alarms monthly. Remove the floating scum layer in all pump/storage tanks
.mping the septic tank solids out.
the spray irrigation system monthly to verify: proper operation of the spray heads; that there are no leaks;
-tative growth does not obstruct the spray heads; that the irrigated wastewater is not ponding in or running
.esignated irrigation area; and that there are no objectionable odors. (if applicable)
.he drip irrigation system monthly to verify: proper operation of the drip lines; that there are no leaks; that
ve growth does not obstruct the drip emitters; that the irrigated wastewater is not ponding in or running off
mated irrigation area; and that there are no objectionable odors. (if applicable)
1 a set of Division -approved engineering plans and specifications.
required annual fee.
renewal of this permit on Division -approved forms no later than 180 days prior to expiration.
1 provide a Change of Ownership application to any future owner of the single-family residence wastewater
it and irrigation system for their completion and submission to the Division of Water Resources.
tand the above requirements and agree to these terms as part of the issued permit.
6. Date:
Date:
Date:
Date:
All deeded proper owners shall sign this Operation and Maintenance A reement

Was the facility originally permitted or had a major modification issued after September 1, 2006?
❑ Yes — Pursuant to 15A NCAC 02T .0105U, submit a site map pursuant to the requirements in 15A NCAC 02T .0
requirements are:
❑ A scaled map of the site with topographic contour intervals not exceeding 10 feet or 25 percent of total site relic
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, in
perennial), springs, lakes, ponds, and other surface drainage features within 500 feet of all wastewater trey
and irrigation sites.
❑ Delineation of the compliance and review boundaries per 15A NCAC 02L .0107 and .0108, and 15A NCAC
❑ 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
©"No — Skip Attachment A.
ATTACHMENT B — SIGNATURE AUTHORITY DELEGATION
Does the signature authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)?
C� 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 w
contributed per unit for the 12 months prior to permit renewal. If any of these monthly averages are within 20% c
flow reduction value, the Permittee shall provide a reevaluation of the reduced flow value pursuant to the requir
INTCAC 02T .0114 .
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 irrigatic
[}Yes — Skip Attachment D.
❑ No — Pursuant to 15A NCAC 02T .0116(c), provide a copy of all easements, lease agreements, and encroachm(
allowing the Permittee to operate and maintain the wastewater collection, treatment, conveyance, and irrigat
property not owned by the Penmittee.
ATTACHMENT E — AFFILIATIONS
Are the Permittee's affiliations of record correct? Check affiliations.
[Yes — Skip Attachment E.
❑ No — Provide the corrected affiliations and their contact information.
ATTACHMENT F — COMPLIANCE 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.
E No — Skip Attachment F.

littee have any existing civil penalties or outstanding violations?
. penalties) — Submit payment for the civil penalty, or proof of remission request.
ations) — Submit a copy of your response to the Notice of Violation.
r Attachment G.
ATTACHMENT H — SETBACK WAIVERS
:ing permit include setback waivers?
rsuant to 15A NCAC 02T .0606(c), provide setbacks waivers that have been written, notarized, signed by all parties
and recorded with the county Register of Deeds. Waivers involving the compliance boundary shall be in accordance
NCAC 02L .010- .
) Attachment H.
APPLICANT'S CERTIFICATION
-7l) 6N 9 . ►J L-wo C-A _ attest that this application
(Signature authority's name as noted in Section I, Item 3)
-wed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of this
ickage are not completed, and that if all required supporting information and attachments are not included, this
ckage will be returned as incomplete. I further certify pursuant to 15A NCAC 02T .0120(bl, that the applicant, or any
iary, or other affiliate of the applicant has: not been convicted of environmental crimes under; not previously abandoned
Teatment facility without properly closing the facility; not paid a civil penalty; not been compliant with any compliance
permit, settlement agreement, or order; not paid an annual fee.
)plicant's Certification shall be signed pursuant to 15A NCAC 02T .0106(b1. An alternate person may be delegated as
'facial if a letter is provided pursuant to 15A NCAC 02T .0106(c). Pursuant to § 143-215.6A and § 143-215.6B, any
iowingly makes any false statement, representation, or certification in any application package shall be guilty of a Class
)r, which may include as fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
l f - Date: L! _ O) 3
METED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email: Laserfiche Upload:
ion-Discharpe.Reports(#)ncdenr.eov https://edocs.deg.ne.gov/Forms/NonDischarge-Branch-
Submittal-Form-Vert