WQ0010736_Application_20240604

Department of Environmental Quality
Division of Water resources
[)Msion of Watrr Itesourers,
I -,%A NCAC 02T.06—SINGLE,F MILY RESIDENCE
WASTEWATER HM A-nON SYSTEM— RENEWAL
FORM' SFR vlri' 1 -H 02- i
Pursuant to J�4 NCAC 02T.01117011 if the application does rant include all Mquired information and the necessary w"pporting
documeptation, the npptication shall be returned. The application and anachments shall be prep2red in ;accordance with LLk
021 J5 N AC Ij_ .i1G+M+►, and 12j--ijon Pqlicit For more information. Visit the Water QuaJiq Permitting
Section's Nan -Discharge Brianch m ebsit . The Applicant shall wbmit an elmronic cope of the application and attachments
uploaded as a sinpje Portable Document Format (PDF) file to hit juOtdoc,. d g, kc hwrge-Ur2avjL-
Submitud-fionia-Ver2, or emailed to - z ; - " P% if less than 241 megab)ies (lai$).
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SECTION I —APPLICANT L FORXAT ON
Applicant Eluabeth C. Moore
Perni t No W o010736
Signature authority F.iiz*cth C. Moa(ae
4. Mailing address: 3&A Nbson Rd.
City New Hill
5. Comact person: Elizabeth C. Moore
Prinian- phone number. �919) 434-8437
6. &wndan Contact person:
Pri man phone number: ( ) -
L Ph%-sical address; :3 ti4 I►4=n Rd
C ipv : T m%- Hill
I- Bitling address, 3904 Mason Rd.
City: Neu Hill
Title- -ner
Stale:IVY' Zip 27562
Email: %icton-hill'eibellsouth,net
ecorKL-m phone number. f 1 -
Email:
eccndan phone number: 1 ! -
ECTION It — IF' C R. nY VUORNFA13ON =
County: Wake
Mate- NC Zip: 27562
Et~ `nON ID — BILLING iiTFUR:I1�fhTI
?- Verify the Applicant does not Kave am overdue a mxW fees:
sate: NC Zip. 27562
Pursuant to 15A NCAC 02T.11120(c 1. pernuts for recrex -Og facilities sUl not be gmrtted if the :applicant or axle- affitliation has
an unpaid annual fee.
FORM- SFR -R 02- 1 Page 1 of 4

ECTI0 N IN' -0 PERATIO N'D SLAISTE ANC'E AGREEMENT
Permit No.: WQOO10736 County: Wake
Pennitlee- Elizabeth C. Moore (i.e., all deeded proper[ mvners)
The Permittec agrees to operate and maintain the single-family residence wastewater treatmmi and 1M'gation System
as folloxv5M +
L Inspect the septic taut: annual li, and pump out solids as needed
? Inspect acid clean ibe s tic tank effluent filtcrannually. (Ifagplicablel
lttspect the tablet chlorinator We) klw. Add w rite r a chlorine tablets e.g,, calcium llw ocl�loWe) as
needed. Sivimming pcol grade chlorine Lblets are not acceptable- ffopplicable)
4. lnspcct the ultraviolet disinfection unit lveekl%. Clean or replace the lamps and quarU sleeves as needed. Qf
applicable) f
. Inspect all storage tanks, pumps. and alarms monthly- Remove the floating scum fa�•er in all pump/storage tanks
,when pumping the septic tank solids out- -
6. Inspect the spray irrigation s}stem month]y to proper operation of die spra} heads: that there are no leaks. -
that vegetative gro-wth does riot obstruct the spray heads: that the irrigated w =myater is not ponding in or nuxning
off the designated irrigation tea: and that them are no objectionable odors, l 'applrrable)
7. hiRxet the drip irrigation systcm monthly to vcrif� . proper operation of the drip lines: that there acre no Icaks: Ilia[
vegetath,e gro, h does not obstmo the drip emitters; that the irrigated w%astew ale is not ponding in or running off
tine desim mied irrigation area: a.ad that there re ano ob�ectionahle odors. Ot`applicable)
8 Maintain a set of Division -approved cngrneerin_a plans and specifications_
9. Pay the requi red wmuai f .
10- Request rc=N- l of this penult on Division roved forms no later thwi 180 days prior to expiration.
II - Sign and provide a Chwiw of_Oi4aershio acQ cat,ar� to anv future owner of the single-family residence
wastewater trcWmcnt and irrigation system for their completion and submission to the: Division of Water
lsnuroes
lA e understand thi
Signature -
Signature:
as part of the issued permit.
Date
Date
Signature- _ Date
signature:. Dare
shalt.Atgrj this Opeirafien allLd Maintenance Agr-Unleal
FORM FRWWI -R (12-2 l Page 2 of 4

-ATTACHMENT N T A- SITE 14 "
%Vas the f' }lily ongu-Al peornticd or had a major modification issued after September J. 20061
Yes - Pursu m to 15A NCAQ 021[ _tMLO _ suhraiz a site map pumwnt to the requitmrnent5 in.1; C C ?T _ttAAd)_ Thme
Mquirements are:
A scaled map of the site with topographic comouir intervals not ea=edmg 10 feet or 25 percent of total site mlief and
ftwing all facility-reialed gmm urges and fences within the wastenvater t ttment- storage, and irrigation ems.
Soil mapping units sltown on 311 irrigation sites.
The location of all swells (including usage and constniction details if available). stmams (ephemeral. intermittent. and
perenrdal}. springs. lakes. ponds.. and otber surface drainage fmhm ithin 5M feet of all 3asiovatcr treatmerd, storage.
and irrigation sites-
DehDcation of the compliance and review boundaries per 15A NCAC .L-] I+1 r and .tL 1j1& and I ; A NC AC g42T 0601.
Selbacks as mqWred by j 5A NC"AC Ii?T .t .
Site property- boundaries within 500 feet of all Matment. storage. and irriggtion sites.
All habitable residences or places of public assembh- ilitMn 3W feet of all mum nt, storage, and irrigation sites.
No - Skip Attachrr ni A.
�f ATTACHNWff 2 - SIGNATUM AV=ORM D it L EGATIO
Does the signature autltonl►- in Section 1. hem 3 meet the requtremcats pursuant to 15 A NLCAC UIT M+Mf1t t :'
Yes - Skip Attachment 5-
No - Submit a d6wiion IcILU pursuant to 1 3 A NCAC o-T _Q 1(k authorizing the signature authority to sign.
ATT'ACH11 ' C - FLADW REDUCTION
Does the msun,g permit include an approved f1ol;. nk&X1j0n`'
Yes - Suhriah a cop}- of the flow reduction approval letter. as vi ell as the measured mandih, average asrxo= of wastewater flou-
coumbuted per unit for the 12 m nffis prior 10 permit rent}a.l_ if arm of these monthly averages ate %within 209/6 of the approved
flows reduction value. the Permillee shall pr€ vide a ree-valuation of the reduced flown value pursuant to the requirement's in 15A
NCAC 11-_+t1_14 ft,
No - Skip Anach=nt C.
ATTACHMENT D - EASEMENT, UNCR ACKMENT,AND LEASE AGREENIM -
Does the P+ermiuec ow3-n all ofthe land associated xvith the -- t -, ., ,..tear -collection. treat=nl, conveyance. and irrigation system ?
Fes - Skip Attachment D.
No - Pursuant to 1.5A NCAC 02T,01 INcl. provide a cop- of aH easements, lease agreement& and encroaCltwnt ao La
allowing the Permit= to operate and makaain the waam2t,es collecliom treatment. conveyance. and irrigation System orM
proper - not m%-ned b}- the Perautlee_
ATTACHhIE.NT E-AFFILLA3'IONS
Are the Pcrvr�rtee`s a.f1"iliatiosts of record cortect? ClVclr ff-IIQLu0n,
Yes - Skip Attachment E.
No - Prmide the corrected affidiations and their eon t infbm-miion.
ATTA 1l 3MN T F - Cf3MPL,IANCE' SCHE DGLFS ;
Does the existing pemiit include am Compliance chcdules'?' (See Sectiou 1 of the nmst mcendy issued permit)
Yes - Submit docurnicnMtation drat the corapliance schedules hew-- been met_
No - Skip Attachment 1=
l=OM. SFRWW 1S-R 0 21 Page 3 of 4

V 7 7 ATTACIi'1iENT G -MILIPENALTIFS AND OUTSTANDUNG VIOLATIONS
Does the Fennitwe have any emoting zap il penalties or outstwid.ing �IDb . li ,
Yes (cit-il p tried -Submit ps3-meat for the chit pertalry or proof of
Yes (lHolations) - Submit a copy' of your response to the Notice of Violati =
No - Ship Attachment C.
Ir
ATTACH MMNT H - SMMA" WAIVERS
Does tt+e cxmmg permit include setback r*-mi-ers"
Yes - Pursuant to 15 A NCAC Q2T _t.» Wpfc i. pmvide setbacks waiver UAal lave been n n"On. wtarized, signed by all parties
im-owed- and recorded with the county Resister of Nerds. Waivers iffmo ring the compliance boundary- slop. be in a.....
with -15,6 N AC 02L 111-1.
- Skip Atmchrmw H_
* APIPLICAN-rS CERTIFICATION
application
(SrgrOuire authonh -S Ra= as noted in Section L Item 3)
amid that this
has been revie%%ed b�me and is a crate and complete to the best of m,. knon�ledge. I w)derstud that if all required parts of this
application packager are riot cor vleted< and that if all required supporong information and attachments am nOL included, this
application package will be reitwed as inconrlete. I funber certif►- pursu= to I J A NCAC I IIT .01 !Ojb). that the applicant. or ark-
parent, subsidiary-, or otler afftiate of die applicant` has- ax been eoavicted of erwiromrbenW cnntes under. not pmwiously
abandoned a wasto ater U=tmcM facility vvitl to pit, closing the not paid a civil penal : not been compliant with
any conipliwruoe schedule in a permit. settlement agreeirrnL or order.. not paid an aru =l f .
Note, The Applicant's trerufie-atinn shall be signed purs=a to t 5A CA C 911Al I i!(, tQW. An alterrurle person may be delegated as
llle signing official if a brier is provided pnrnaM to 13 AA\CAC tP?T 411(6(cI. Pumam to § 1A3-?15.6 and § 14 -21 ;1-6B, all),
person who 1. , �.'..J1 ' makes Ise staterneriL represe n_ or certification in amapplication package shall be guilty of a
Class 2 misdemeanor, 114-hicfi La 1 not to exceed $10,0M as well s ciyil penalties up t 21.(01 per violation_
Signature: Date'
�fi f
THE COMiPLETED APPLICAT I0'4 AND ATTACTfKK%T'S SHALL BE SUMa,, , t.KJ AS A SINGLE PDF FILE VIA:
Ems=
La rficbe Upload:
.'ubmitlal-For_mA i,,
FORM: SFRW I -R 02-21 Page 4 of 4