WQ0004938_Application_20231101

DocuSign Envelope ID: F892ADAD-C84C-4AAl-BC8B-054960274AOF
ROY COOPER
Governor
ELIZABETH S. B1SER
Secretary
RICHARD E. ROGERS, JR.
Director
NORTH CAROLINA
Environmental Quality
September 27, 2023
JERRY C. SAUNDERS AND DEEANN C. SAUNDERS
68 &PAGETOWN ROAD
BURLINGTON, NORTH CAROLINA 27217
Subject: Permit No. WQ0004938
Permit Renewal Notification
681tR Pagetown Rd. SFR
Single -Family Residence
Wastewater Irrigation System
Alamance County
Dear Mr. and Mrs. Saunders:
Division of Water Resources' records indicate that Permit No. WQ0004938, issued May 25, 2017,
expired April 30, 2022. As the Permittee, you are responsible for renewing and maintaining this permit.
Pursuant to administrative code 15A NCAC 02T .0109, permit renewal requests shall be submitted at least
180 days prior to permit expiration.
Please complete and submit the attached Single -Family Residence Wastewater Irrigation System
Renewal application (Form: SFRWWIS-R 02-21). This form has been prefilled for your convenience.
Please complete any portions that are not filled out and double-check all information for accuracy.
Within 30 calendar days of receivine this notification submit the completed forms to:
Email:
Non-Dischar.=e.Reportsrii)ncdenr. tiov
Mail:
Attn: Alys Hannum
OR Non -Discharge Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Once the application is received, Winston-Salem Regional Office staff will conduct a site visit and
inspect the non -discharge system. Upon completion of the site visit and application review, a renewed non -
discharge permit shall be issued for a length of up to eight years. Failure to provide these forms prior to
the permit expiration date may result in a Notice of Violation for operating the subject facilities without
a valid permit, which is_ a-piolation of G.S. 143-215.1, and may subject the Permittee to appropriate
enforcementpursua t to G.S. 143-215.6AJ6C.
-yo y any quest ns, please contact me at [phone] or [e-mail].
Sincerely, Docu9iyne0by'.
W
'Sow
L"o 7005M04F3...
Alys Hannum, Environmental Specialist
Division of Water Resources
cc: ston-Salem Regional Office, Water Quality Regional Operations Section (Electronic Copy)
Laserfiche File (Electronic Copy)
D,.,- North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 1 1617 Mail Service Center I Raleigh, North Carolina 27699-1617
�� /"� 919.707.9000

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
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 .0107i b i, 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 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 —.tlis:Hedoes.de(i.nc.eov/Forms/NonDischarne-Branch-Submittal-
Form-Vert, or emailed to Non-Dischar2e.Rej)orts a-ncdenr.eov if less than 20 megabytes (MB).
SECTION I — APPLICANT INFORMATION
1.
Applicant: Jerry C. Saunders and Deeann C. Saunders
2.
Permit No.: WQ0004938
3.
Signature authority: Jerry C. Saunders and Decann C. Saunders Title: Owners
4.
Mailing address 6&�� /3
City: Burlington State: NC Zip: 27217-
5.
Contact person: Jerry C. Saunders / 1 y t_I I 10 Email: N/A
Primary phone number: (33) 584-3883 (ivaukolome/cell) Secondary phone number: ( ) - (home/cell/etc)
6.
Secondary Contact person: Deeann C. Saunders Email: A11A,
iL� ISe�condary
Primary phone number: (336) 5Ra� (yoe4 dao e cell phone number: ( ) - (home/cell/etc)
SECTION II — FACILITY INFORMATION
1. Physical address: 6815 Pagetown Rd. County: Alamance
City: Burlington State: NC Zip: 27217-
SECTION III — BILLING INFORMATION
] . Billing address: ft�agetown Rd. (p �S L3 /c:�,7�8 eve JU,
City: Burlington State: NC Zip: 27217-
2. Verify the Applicant does not have any overdue annual fees:
https://deq.nc.gov/about/divisio. /water-resources/water-resources-hermits/wq-epaN ments
Pursuant to 15A NCAC 02T .0120(c!, permits for 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 — OPERATION AND MAINTENANCE AGREEMENT
Permit No.: WQ0004938 County: Alamance
Permittee: Jerry C. Saunders and Deeann C. Saunders (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 a sllication 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 requirements and agree to these terms as part of the issued permit.
Signature: a Date: l��•- �,�=��
j
Signature: ' Date: & 'Z
Signature:
Signature:
Date:
Date:
All deeded proverty owners shall sign this Operation and Maintenance Agreement
FORM: SFRWWIS-R 02-21 Page 2 of 4

ATTACHMENT A — SITE MAP
Was the facility originally permitted or had a major modification issued after September 1, 2006?
❑ Yes — Pursuant to 15A NCAC 02T .01051 dl. submit a site map pursuant to the requirements in 15A NCAC 02T .0604i d 1. These
requirements are:
❑ A scaled map of the site with topographic contour intervals 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 surface drainage features within 500 feet of all wastewater treatment, storage,
and irrigation sites.
❑ Delineation of the compliance and review boundaries per 15A NCAC 02L .0107 and .0108, and 15A NCAC 02T .0601,
❑ 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 sites.
A 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 .0106tb1?
Yes — Skip Attachment B.
❑ No — Submit a delegation letter pursuant to 15A NCAC 021.0106i cl authorizing the signature authority to sign.
ATTACHMENT C — FLOW REDUCTION I
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 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 provide a reevaluation of the reduced flow value pursuant to the requirements in 15A
NCAC 02T .0114(E).
No — Skip Attachment C.
ATTACHMENT D — EASEMENT, ENCROACHMENT, AND LEASE AGREEMENTS
Does the Penmittee own all of the land associated with the wastewater collection, treatment, conveyance, and irrigation system?
;,Yes — Skip Attachment D.
❑ No — Pursuant to 15A NCAC 02T .0116(c), provide a copy of all easements, lease agreements, and encroachment agreements
allowing the Permittee to operate and maintain the wastewater collection, treatment, conveyance, and irrigation system on
property not owned by the Permittee.
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.
No — Skip Attachment F.
FORM: SFRWWIS-R 02-21 Page 3 of

I ATTACHMENT G — CIVIL PENALTIES AND OUTSTANDING VIOLATIONS
Does the Permittee have any existing civil penalties or outstanding violations?
❑ Yes (civil penalties) — Submit payment for the civil penalty, or proof of remission request.
❑ Yes (violations) — Submit a copy of your response to the Notice of Violation.
No — Skip Attachment G.
ATTACHMENT H — SETBACK WAIVERS
Does the existing permit include setback waivers?
❑ Yes — Pursuant to 15A NCAC 02T .0606M, 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.
I APPLICANT'S CERTIFICATION I
1, attest that this application
(Signature authority's name as noted in Section I, Item 3)
has been reviewed by me and is accurate and complete to the best of my knowledge. l 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 .0120tb} 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 Applicant's Certification shall be signed pursuant to 15A NCAC 02T .01061b1. An alternate person may be delegated as
the signing official if a letter is provided pursuant to 15A NCAC 02T .0106(c). Pursuant to § 143-215.6A and § 143-215.6B, any
person who knowingly makes any false statement, representation, or certification in any application package shall be guilty of a Class
2 misdemeanor, which may include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature:
Date: - 3
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email:
Non-Discharue.Renortsca ncdenr.pov
Laserfiche Upload:
httns J/edocs.de(i.ne.Eov[Forms/NonDischa rge-Branch-
Submittal-Form-Ver2
FORM: SFRWWIS-R 02-21 Page 4 of 4