WQ0014589_More Information Received_20241125

Initial Review
Reviewer
nathaniel.thornburg
Is this submittal an application? (Excluding additional information.) *
Yes No
If not an application what is the submittal type?* Annual Report
Residual Annual Report
Additional Information
Other
Permit Number (IR) * W00014589
Applicant/Permittee Michael D. Pittard and Jean M. Pittard
Email Notifications
Does this need review by the hydrogeologist? * Yes No
Regional Office
CO Reviewer
Admin Reviewer

Submittal Form
Project Contact Information
Please provide information on the person to be contacted by NDB Staff regarding electronic submittal, confirmation of receipt, and other correspondence.
..................................................................................................................................................................................................................................................................................... ... ... ... ... ... .. ... ... ... ... ..
Name* Michael Pittard
Email Address*
[e-mail]
Project Information
.........................
Application/Document Type*
New (Fee Required)
Modification - Major (Fee Required)
Renewal with Major Modification (Fee
Required)
Annual Report
Additional Information
Other
Phone Number*
3362133458
Modification - Minor
Renewal
GW-59, NDMR, NDMLR, NDAR-1,
N DAR-2
Residual Annual Report
Change of Ownership
We no longer accept these monitoring reports through this portal. Please click on the link below and it will take you to the correct form.
https://edoes.deq.nc.gov/Forms/NonDischarge_Monitoring_Report
Permit Type:*
Wastewater Irrigation
High -Rate Infiltration
Other Wastewater
Reclaimed Water
Closed -Loop Recycle
Residuals
Single -Family Residence Wastewater
Other
Irrigation
Permit Number:*
WQ0014589
Has Current Existing permit number
Applicant/Permittee Address*
3106 Amherst Ave, Burlington, NC 27215
Facility Name*
6354 NC 86 S SFR
Please provide comments/notes on your current submittal below.
I am sending the additional information requested for the renewal application.
At this time, paper copies are no longer required. If you have any questions about what is required, please contact Nathaniel Thornburg
at [e-mail].
Please attach all information required or requested for this submittal to be reviewed here.
(Application Form, Engineering Plans, Specifications, Calculations, Etc.)
WQ0014589_Additional Information_20241120.pdf 2.51 MB
Upload only 1 PDF document (less than 250 MB). Multiple documents must be combined into one PDF file unless file is larger
than upload limit.
* By checking this box, I acknowledge that I understand the application will not be accepted for pre -review until the fee (if required) has
been received by the Non -Discharge Branch. Application fees must be submitted by check or money order and made payable to the
North Carolina Department of Environmental Quality (NCDEQ). I also confirm that the uploaded document is a single PDF with all parts
of the application in correct order (as specified by the application).
Mail payment to:
NCDEQ — Division of Water Resources
Attn: Non -Discharge Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Signature
Submission Date 11/25/2024

IMRNC Department of Environmental Quality State of North Carolina
;..�... a Received Department of Environmental Quality
NOV 2 2 2024 Division of Water Resources
Division of Water Resources 15A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE
�.
Winston-Salem WASTEWATER IRRIGATION SYSTEM — RENEWAL
�
FORM: SFRW W IS-R 02-21
M-4i7 . - flffira
Pursuant to ISA NCAC 02T .0107fb), 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 02'I' .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://edocs.de(i.ne.2ov/Forms/NonDischar2e-
Branch-Submittal-Form-Ver2, or emailed to Non-Discharffe.Reports(a nedenr.Eov if less than 20 megabytes (MB).
�i licanL <Iichael D. Pittard
Permit No.: WQ0014589
Signature authority: Michael D. Pittard
4. Mailing address: 3106 Amherst Ave
City: Burlington
5. Contact person: Michael D. Pittard
Primary phone number: [phone] Cell
6. Secondary Contact person: Jean M. Pittard
Primary phone number: [phone] Cell
Title: Owner
State: NC Zip: 27215-
Email:
Secondary phone number: ( ) - Select
Email:
Secondary phone number: ( ) - Select
I FACILITY f T20N
l . Physical address: 6354 NC 86 S County: Caswell
City: Yanceyville State: NC Zip: 27379-
RM: SFRWWIS-R 02-21 Page 1 of

SECTION IV
Permit No.: WQ0014589
Permittee: Michael D. Pittard (i.e., all deeded property owners)
County: Caswell
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.
Inspect and clean the septic tank effluent filter annually. (ifapplicable)
Inspect the tablet chlorinator weekly. Add wastewater grade chlorine tablets (e.g., calcium hypochlorite) as
needed. Swimming pool grade chlorine tablets are not acceptable. (ifapplicable)
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. (ifapplicable)
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. (ifapplicable)
8. Maintain a set of Division -approved engineering plans and specifications.
} 9. Pay the required annual fee.
Request renewal of this permit on Division -approved forms no later than 180 days prior to expiration.
Sign and provide a Change 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: /.�- �� �'-'-�•-� Date: � 7
i
Signature: Date:
Signature: Date:
Signature: Date:
All deeded property owners shall sign this Operation and Maintenance Agreement
FORM: SFRWWIS-R 02-21 Page 2 of

Eaii0''°1'..''",
Was the facility originally permitted or had a major modification 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 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.
❑ Scthacks as required by 15A NCAC 02T .0606.
J Site property boundaries within 500 feet of all wastewater treatment, storage, and irrigation sites.
❑ A i I habitable residences or places of public assembly within 500 feet of all treatment, storage, and irrigation sites.
r�❑ No Skip Attachment A.
(,, E3C. , r,€ E i ,�,s{a X wi, € ..u' EE,;:r„ 'd€ilffii •.. ..
l:a?re' :
Does the signature authority in Section 1, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)? ❑
®❑ Yes — Skip Attachment B.
❑ No — Submit a delegation letter pursuant to 15A NCAC 02T .0106(c) authorizing the signature authority to sign.
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 .01 14(f).
®❑ No — Skip Attachment C.
::es the Perri ittee 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.
K:(:Es
�, h,..vS,S s, b,ws� ..ate ,,. ,,,F �J ,,:,�."�..,__..�...� 'Y,%,t.1f •. ..,a
Are the Permittee's affiliations of record correct? Check affiliations.
®❑ Yes — Skip Attachment E.
❑❑ No — Provide the corrected affiliations and their contact information.
It - - €.�,.€„ xSiE ''�sEuyf Tts1ub € - [€ €,
.�.�,,,�G:r ..�.��x ff,ct€� €�€ n 'SEC ,�w�nE,f�f ,6�. �Ef.. i€. €��€E;- �. <<�(�' €.
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

IVALTI.ES i
Does the Perm ittee 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.
,/Y, e,/,", / D, /, �- h-'arW
(Signature authority's name as noted in Section I, Item 3)
attest that this
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 § 143-215.613,
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.
;,,nature: 07"" D' (/ �'Date: 1-4 r�'�a Li
FHE COMPLETED APPLICATION .AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email-
Non-Discharge.Reports�,ncdenr.Eov
Laserfiche Upload:
https:Hedoes.deq.nc.Eov/Forms[NonDischa rge-B ranch -
Submittal -Form -Vert
FORM: SFRWWIS-R 02-21 Page 4 of 4