WQ0004216_Application_20240327

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 — CHANGE OF OWNERSHIP
FORM: SFRWWIS-CO 03-21
Pursuant to 15A NCAC 02T .0107(bl, 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.deu.nc.gov/Forms/NonDischarae-Branch-Submittal-
Form-Vert, or emailed to Non-Discharee.ReportsC ncdenr.Qov if less than 20 megabytes (MB).
SECTION I — APPLICANT INFORMATION
1.
Applicant: Annette G. Barker and Wayne S. Barker
2.
Permit No.: WQ0004216
3.
Signature authority: Annette G. Barker and Wayne S. Barker
Title: Owners
4.
Mailing address: 1 %66 '4aX4-1� ]
a -
City: t -
State: Zip: C31
5.
Contact person: Anrt to G. Barker
Email: r QOC�C�SO rl C��Qs'-k- Cn 1.t�S q
Primary phone number: (ayp) -mkk Select
Secondary phone number: ( ) - Select
6.
Secondary Contact person: Wayne S. Barker
Email:
Primary phone number: 6�Stz)&j -%'K Select
Secondary phone number: ( ) - Select
SECTION II— FACILITY INFORMATION
1. Physical address: 1404 Staley Boswell Rd.
City: Yanceyville
County: Caswell
State: NC
Zip: 27379-
SECTION IH — BILLING INFORMATION
1. Billing address:
City: State: Zip: -
SECTION IV — DEED INFORMATION
Has a deed been executed and recorded in the County Register of Deeds pursuant to 15A NCAC 02T .0604(e)(1)?
® Yes — Complete Items 1 through 4 below.
❑ No — See Attachment B on Page 3.
1. Parcel No.: 0072 002
3. Deed Book: 649
2. Date of Purchase: May 2, 2023
4. Deed Page Nos.: 995 - 997
,4It
FORM: SFRWWIS-CO 03-21 Pagel of 3

SECTION V — OPERATION AND MAINTENANCE AGREEMENT
Permit No.: WQ0004216 County: Caswell
Permittee: Annette G. Barker and Wayne S. Barker (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 Chan e of Ownership application 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: mti'n Date: 3
Signature: G Date: , - a
Signature:
Date:
Signature: Date:
All deeded pronert► owners shall stm this Operation and Maintenance Aureement
FORM: SFRWWIS-CO 03-21 Page 2 of 3

ATTACHMENT A — SIGNATURE AUTHORITY DELEGATION
Does the signature authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)?
❑ Yes — Skip Attachment A.
❑ No — Submit a delegation letter pursuant to 15A 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(t)(1)?
® Yes — Complete Items 1 through 4 in Section IV on Page 1.
❑ 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 of the property and has been signed by
both parties, as well as a plat or survey map pursuant to 15A NCAC 02T .0604te}(3. Lease agreements shall adhere to the
requirements of 15A NCAC 02L .0107.
APPLICANT'S CERTIFICATION
I, ` (l �_ C �_'��, t_ _ __ 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. I 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 .0120(b), 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 .0106(b). 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: R MM ,, k:�,- (1-, �(i��L �t �c Date: ' 1), L
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email:
Non-Discharge.ReoortVa ncdenr.aov
Laseriiche Upload:
_https: /Iedocs. deg.ne.gov/Form s/NonDischarge-Branch-
Submittal-Form-Ver2
FORM: SFRWWIS-CO 03-21 Page 3 of 3

DocuSign Envelope ID: 1A3AE1AD-6E8F-4DD9-AD3E-5FOE038C5217
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
NORTH CAROLINA
Environmental Quality
February 22, 2024
ANNETTE G. BARKER AND WAYNE S. BARKER
1260 STALEY BOSWELL ROAD
YANCEYVILLE, NORTH CAROLINA 27379
Subject: Permit No. WQ004216
Change of Ownership
1404 Staley Boswell Rd. SFR
Single -Family Residence
Wastewater Irrigation System
Caswell County
Dear Mr. and Mrs. Barker:
It has come to the Division of Water Resources' attention that the subject single-family residence
wastewater irrigation facility has changed ownership. The Caswell County Register of Deeds indicates that
you acquired the subject property (Parcel No. 0072 002) on May 3, 2023 (Deed Book: 649 / Page: 995).
The wastewater treatment and irrigation system associated with this property are covered under an
individual State -issued non -discharge permit (Permit No. WQ0004216). Accordingly, please complete and
submit the attached Non -Discharge Permit Change of Ownership application (Form: SFRWWIS-CO 03-
21). This form has been prefilled for your convenience.
Once the application is received, Winston-Salem Regional Office staff will conduct a site visit and
provide an overview of the treatment and disposal system. Upon completion of the site visit and review of
the application, a new non -discharge permit will be issued for a length of up to eight years. There is a $60
annual fee associated with this permit, which is not due at this time.
Please complete and submit the attached forms within 30 calendar days of receiving this
notification. Failure to provide these forms shall result in a Notice of Violation for operating the
subject facilities without a valid permit, which is a violation of G.S. 143-215.1, and may subject you
to appropriate enforcement actions pursuant to G.S. 143-215.6A-6C. Civil penalties of up to $25,000
per day per violation may be assessed for failure to secure a valid permit.
If you need additional information concerning this letter, please contact me at [phone] or
alvs.hannum(&deq.nc.IZ .
Sincerely, DoeuSigned by,
Q ?V..
4C22170CSM04F3...
Alys Hannum, Environmental Specialist
Division of Water Resources
cc: Laserfiche File (Electronic Copy)
Digital Permit Archive (Electronic Copy)
��� North Carolina Department of Environmental Quality I Division of Water Resources
E512 North Salisbury Street 1 1617 Mail Service Center I Raleigh, North Carolina 27699-1617
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919.707.9000