WQ0030465_Final Permit_20170217

Water Resources
ENVIRONMENTAL QUALITY
February 17, 2017
SERGIO & NORMA A. SALAZAR
1547 ANDOVER AvEN UE
GREENSBORO, NORTH CAROLINA 27405
Dear Mr. & Mrs. Salazar:
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
S. JAY ZIMMERMAN
Director
Subject: Permit No. WQ0030465
2060 Stewart -Hutchens Rd. SFR
Single -Family Residence
Wastewater Irrigation System
Guilford County
In accordance with your permit renewal request received December 7, 2016, we are forwarding
herewith Permit No. WQ0030465 dated February 17, 2017, to Sergio and Norma A. Salazar for the
construction and operation of the subject single-family residence wastewater treatment and irrigation
facilities.
This permit shall be effective from the date of issuance until January 31, 2022, shall void Permit
No. WQ0030465 issued March 7, 2007, and shall be subject to the conditions and limitations as specified
therein. An extension shall be requested at least six months prior to the expiration of this permit.
Upon receipt of the request, the Commission will review the adequacy of the facility described therein and,
if warranted, will extend the permit for such period of time and under such conditions and limitations as it
may deem appropriate.
Please pay particular attention to the operation and maintenance requirements listed in Section III
for they may differ from the previous permit issuance. Failure to establish an adequate system for collecting
and maintaining the required operational information shall result in future compliance problems. Also note
that Condition VI.6. requires the Permittee to retain a set of Division approved plans and specifications for
the life of the facilities permitted herein.
Please note the following permit conditions have been removed since the last permit issuance
dated March 7,2007:
> Old Condition I.5 — Condition L 1 of this permit requires an Engineer's Certification. This will
serve as evidence that the sand media of the subsurface sand filter complies with the Division's
sand specifications.
➢ Old Condition I.6 — Condition I.1 of this permit requires an Engineer's Certification. This will
serve as evidence that the septic/pump tank(s) are installed correctly and do not exceed an
exfiltration rate of 20 gallons per 24 hours per 1,000 gallons of tank capacity.
➢ Old Condition I.8 — Condition 1.1 of this permit requires an Engineer's Certification. This will
serve as evidence that a sanitary tee and filter are installed on the effluent pipe of the septic
tank.
-""'Nothing Compares—— -.
State of North Carolina I Environmental Quality I Water Resources j Water Quality Permitting I Non -Discharge Permitting
1617 Mail Service Center I Raleigh, North Carolina 27699-1617
919-807-6332

W. Sergio Salazar & Mrs. Norma A. Salazar
February 17, 2017
Page 2 of 2
Please note the following permit conditions are new since the last permit issuance dated
March 7,2007:
➢ Condition I1.4. — This condition includes information about the wastewater irrigation field.
➢ Condition 111.7. — This condition establishes the compliance boundary at the property boundary
in accordance with 15A NCAC 02L .0107(i).
➢ Condition II.8. — This condition establishes the review boundary midway between the
compliance boundary and the disposal area in accordance with 15A NCAC 02L .0108.
➢ Condition H.9. — This condition requires the Permittee to apply for a permit modification to
establish a new compliance boundary if any sale or transfer of property affects the existing
compliance boundary.
➢ Condition IV.2.c. — This condition requires the Permittee to notify the Division any time self-
monitoring indicates the facility has gone out of compliance with its permit limitations..
➢ Condition IV.2.d. -- This condition requires the Permittee to notify the Division any time there
is ponding in or runoff from the irrigation sites.
➢ Condition VI.7. — This condition requires the Permittee to maintain this permit until all
permitted facilities are properly closed or permitted under another permit.
➢ Condition V1.8. — This condition notifies the Permittee that this permit is subject to revocation
or unilateral modification upon 60 days notice from the Division Director, in whole or part for
the requirements listed in 15A NCAC 02T.0 110.
➢ Condition V1.9. — This condition notifies the Permittee that unless the Division Director grants
a variance, expansion of the permitted facilities contained herein shall not be granted if the
Permittee: has been convicted of an environmental crime; has previously abandoned a
wastewater treatment facility; has not paid a civil penalty; is non-compliant with a permit
schedule; or has not paid an annual fee.
If any parts, requirements or limitations contained in this permit are unacceptable, the Permittee
has the right to request an adjudicatory hearing upon written request within 30 days following receipt of
this permit. This request shall be in the form of a written petition, conforming to Chapter 150B of the North
Carolina General Statutes, and filed with the Office of Administrative Hearings at 6714 Mail Service
Center, Raleigh, NC 27699-6714. Unless such demands are made, this permit shall be final and binding.
If you need additional information concerning this permit, please contact Ashley Kabat at (919)
807-6248 or ashley.kabatkncdenr.gov.
Sincerely,
,?-S. Jay Zimmerman, P.G., Director
Division of Water Resources
cc: Guilford County Health Department (Electronic Copy)
Winston-Salem Regional Office, Water Quality Regional Operations Section (Electronic Copy)
Digital Permit Archive (Electronic Copy)
Central Files

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEM PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules and Regulations
PERMISSION IS HEREBY GRANTED TO
Sergio & Norma A. Salazar
Guilford County
FOR THE
construction and operation of a 480 gallon per day (GPD) single-family residence wastewater treatment
and irrigation facility consisting of:
a 1,500 gallon septic tank; dual 210 square foot (ft) subsurface sand filters; a chlorine disinfection system;
dual 1,200 gallon storage tanks; a 700 gallon storage/pump tank with a 13.5 gallon per minute (GPM) 0.5
horsepower (hp) pump, and audible/visual high-water alarms; a moisture sensor; a 0.31 acre drip irrigation
area with two 0.155 acre zones; and all associated piping, valves, controls, and appurtenances
to serve the single-family residence at 2060 Stewart -Hutchens Rd., Whitsett, NC 27377, with no discharge
of wastes to surface waters, pursuant to the application received December 7, 2016, and in conformity with
the project plans, specifications, and other supporting data subsequently filed and approved by the
Department of Environmental Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until January 31, 2022, shall void Permit No.
WQ0030465 issued March 7, 2007, and shall be subject to the following specified conditions and
limitations:
I. SCHEDULES
Upon completion of construction and prior to operation of this permitted facility, a certification
(attached) shall be submitted from a licensed North Carolina Professional Engineer certifying that the
permitted facility has been installed in accordance with this permit, Division approved plans and
specifications, and other supporting documentation, including the location of all monitoring wells as
applicable. If this project is to be completed in phases and partially certified the Permittee shall retain
the responsibility to track further construction approved under the same permit, and shall provide a
final certificate of completion once the entire project has been completed. Mail the Certification to the
Division of Water Resources, Water Quality Permitting Section, 1617 Mail Service Center, Raleigh,
NC 27699-1617. [15A NCAC 02T .0116]
2. The Winston-Salem Regional Office, telephone number [phone], shall be notified at least 48
hours in advance (excluding weekends and holidays) of operation of the installed facilities such that an
in-place inspection can be made. Notification to the regional supervisor shall be made from 8:00 a.m.
until 5:00 p.m. on Monday through Friday, excluding State Holidays. [15A NCAC 02T .0108 (b)(2)]
WQ0030465 Version 2.0 Shell Version 151201 Page 1 of 7

3. No later than six months prior to the expiration of this permit, the Permittee shall request renewal of
this permit on official Division forms. Upon receipt of the request, the Division will review the
adequacy of the facilities described therein, and if warranted, will renew the permit for such period of
time and under such conditions and limitations as it may deem appropriate. Please note Rule 15A
NCAC 02T .0105(d) requires an updated site map to be submitted with the permit renewal application.
[15A NCAC 02T.0105, 02T.0109, 02T.01 15(c)]
4. If a public or community sewage system is or becomes available, the subject single-family residence
wastewater treatment and irrigation facilities shall be closed and all wastewater shall be discharged into
the public or community sewage system within 180 days of its availability. Prior to the initiation of
these connection activities, appropriate Division approval shall be received. [15A NCAC 02T .0607]
II. PERFORMANCE STANDARDS
The subject non -discharge facilities shall be effectively maintained and operated at all times so there is
no discharge to surface waters, nor any contravention of groundwater or surface water standards. In
the event the facilities fail to perform satisfactorily, including the creation of nuisance conditions due
to improper operation and maintenance, or failure of the irrigation areas to adequately assimilate the
effluent, the Permittee shall take immediate corrective actions including Division required actions, such
as the construction of additional or replacement wastewater treatment or disposal facilities. [15A
NCAC 02T .0108(b)(1)]
2. This permit shall not relieve the Permittee of their responsibility for damages to groundwater or surface
water resulting from the operation of this facility. [ 15A NCAC 02B .0200, 02L .0100]
3. Application rates, whether hydraulic, nutrient or other pollutant, shall not exceed those specified in the
following table:
TABLE I — APPLICATION LIMITATIONS
Field Parameter Hourly Rate Yearly Max Units
01284 -- Non -Discharge Application Rate I 0. l 1 I 20.75 I inches
[15A NCAC 02T.06050)]
4. The subject facility has been approved to land apply wastewater effluent on the following fields:
TABLE 2 — IRRIGATION AREA INFORMATION
Field Owner County Latitude Longitude Net Dominant
---Acreage Soil Series
1 Sergio & Norma A. Salazar Guilford 36.0261970 -79.647819° 0.31 Sedgefield
[G. S. 143-215.11
5. The Operation and Maintenance Agreement (attached) between the Permittee and the Division of Water
Resources is incorporated herein by reference and shall be a condition of this permit. Noncompliance
with the terms of the Operation and Maintenance Agreement shall subject the Permittee to all sanctions
provided by North Carolina General Statutes §143-215.6A to §143-215.6C for violation of or failure
to act in accordance with the terms and conditions of this permit. [15A NCAC 02T .0115 (2)]
6. The irrigation system shall be connected to a rain or moisture sensor, which shall indicate when effluent
application is not appropriate in accordance with Conditions IIIA, and III.5. of this permit. [ 15A NCAC
02T .0605(o)]
7. The compliance boundary is established at the property boundary. Any exceedance of standards at the
compliance boundary shall require action in accordance with 15A NCAC 02L .0106. [ 15A NCAC 02L
.0107(i)]
WQ0030465 Version 2.0 Shell Version 151201 Page 2 of 7

8. The review boundary is established midway between the compliance boundary and the effluent disposal
area. Any exceedance of groundwater standards at the review boundary shall require action in
accordance with 15A NCAC 02L.0106. [15A NCAC 02L .0108]
9. The Permittee shall apply for a permit modification to establish a new compliance boundary prior to
any sale or transfer of property affecting a compliance boundary. [15A NCAC 02L .0107(c)]
10. The facilities permitted herein shall be constructed according to the following setbacks:
a. The setbacks for irrigation sites permitted under 15A NCAC 02H .0200 shall be as follows (all
distances in feet):
L Any habitable residence or place of public assembly under separate ownership: 100
ii. Surface waters: 50
iii. Any well with exception of monitoring wells: 100
iv. Any property line: 50
v. Public right of way: 50
[ 15A NCAC Q2H .0219(k)]
b. The setbacks for storage and treatment units permitted under 15A NCAC 02H .0200 shall be as
follows (all distances in feet):
i. Any well with exception of monitoring wells: 100
ii. Any property line: 50
[I 5A NCAC 02H .0219(k)]
III. OPERATION AND MAINTENANCE REQUIREMENTS
1. The facilities shall be properly maintained and operated at all times. The facilities shall be effectively
maintained and operated as a non -discharge system to prevent the discharge of any wastewater resulting
from the operation of this facility. The Permittee shall maintain an Operation and Maintenance Plan
pursuant to 15A NCAC 02T .0604(f). [15A NCAC 02T .0604(f)]
2. Upon the Water Pollution Control System Operators Certification Commission's (WPCSOCC)
classification of the subject non -discharge facilities, in accordance with 15A NCAC 08G .0200 the
Permittee shall designate and employ a certified operator in responsible charge (ORC) and one or more
certified operator(s) as back-up ORC(s). The ORC or their back-up shall visit the facilities in
accordance with 15A NCAC 08G .0200, and shall comply with all other conditions specified in the
previously cited rules. [15A NCAC 02T .0117]
3. A suitable year round vegetative cover shall be maintained at all times, such that crop health is
optimized, allows for even distribution of effluent and allows inspection of the irrigation system. [15A
NCAC 02T .0108(b)(1)]
4. Adequate measures shall betaken to prevent effluent ponding in or runoff from the irrigation sites listed
in Condition IIA. [15A NCAC 02T .0605(o)]
5. Irrigation shall not be performed during inclement weather or when the ground is in a condition that
will cause ponding or runoff. [15A NCAC 02T .0605(o)]
6. Only effluent from the single-family residence at 2060 Stewart -Hutchens Rd., Whitsett, NC 27377 shall
be irrigated on the sites listed in Condition 11.4. [G.S. 143-215.1]
7. No automobiles or machinery shall be allowed on the irrigation sites except during equipment
installation or while maintenance is being performed. [15A NCAC 02T .0108(b)(1)]
WQ0030465 Version 2.0 Shell Version 151201 Page 3 of 7

Public access to the irrigation sites and wastewater treatment facilities shall be prohibited. Fencing
shall be provided to prevent access to the irrigation site (minimum 2 -strand wire) and treatment units
shall be secured with locks on all tank accesses and control panels. [15A NCAC 02T .0605(i)]
9. The residuals generated from the wastewater treatment facilities shall be disposed or utilized in
accordance with 15A NCAC 02T .l 100. [15A NCAC 02T .1100].
10. Diversion or bypassing of untreated or partially treated wastewater from the treatment facilities is
prohibited. [15A NCAC 02T .0605(f)]
11. Pump/dosing tanks shall have audible and visual alarms external to any structure. [15A NCAC 02T
.0605(n)]
12. Any excavation into bedrock shall be lined with a 10 millimeter (mm) synthetic liner. [15A NCAC
02T .0605(d)]
13. The Permittee is responsible for the operation and maintenance of the entire treatment and disposal
system including, but not limited to, the following items:
a. The septic tank shall be checked annually and pumped out as needed. The septic tank effluent filter
shall be checked and cleaned at the same frequency as the septic tank. [15A NCAC 18A .1900,
02T .0605]
b. The tablet chlorinator shall be checked weekly. Wastewater grade chlorine tablets (calcium
hypochlorite) shall be added as needed to provide proper chlorination. Pool chlorine tablets shall
not be used. [ 15A NCAC 02T .0605(1)]
c. The storage, pump, and alarm systems shall be inspected monthly. The scum layer in the pump
tanks shall be removed at the same interval as the septic tank is cleaned out. [ISA NCAC 02T
.0108(b)(1)]
d. The system shall be inspected monthly to make certain of the proper operation of the drip lines,
that the system is free of leaks, that the vegetative growth allows a proper drip pattern, that the soil
is assimilating the disposed treated wastewater with no surface runoff, and that no objectionable
odors are being generated. [15A NCAC 02T ,0108(b)(1)]
WQ0030465 Version 2.0 Shell Version 151201 Page 4 of 7

IV. MONITORING AND REPORTING REQUIREMENTS
1. Any Division required monitoring (including groundwater, plant tissue, soil and surface water analyses)
necessary to ensure groundwater and surface water protection shall be established, and an acceptable
sampling reporting schedule shall be followed. [15A NCAC 02T .0108(c)]
2. Noncompliance Notification:
The Permittee shall report by telephone to the Winston-Salem Regional Office, telephone number (336)
776-9800, as soon as possible, but in no case more than 24 hours, or on the next working day following
the occurrence or first knowledge of the occurrence of any of the following:
a. Any process unit failure (e.g., mechanical, electrical, etc.), due to known or unknown reasons,
rendering the facility incapable of adequate wastewater treatment.
b. Any facility failure resulting in a by-pass directly to receiving surface waters.
c. Any time self-monitoring indicates the facility has gone out of compliance with its permit
limitations.
d. Ponding in or runoff from the irrigation sites.
Any emergency requiring immediate reporting (e.g., discharges to surface waters, imminent failure of
a storage structure, etc.) outside normal business hours shall be reported to the Division's Emergency
Response personnel at telephone number [phone], [phone], or [phone]. Persons
reporting such occurrences by telephone shall also file a written report in letter form within five days
following first knowledge of the occurrence. This report shall outline the actions taken or proposed to
betaken to ensure the problem does not recur. [15A NCAC 02T .0105(1)]
V. INSPECTIONS
The Permittee shall provide adequate inspection and maintenance to ensure proper operation of the
wastewater treatment and irrigation facilities. [15A NCAC 02T .0108(b)]
The Permittee or their designee shall inspect the wastewater treatment and irrigation facilities to prevent
malfunctions, facility deterioration and operator errors resulting in discharges, which may cause the
release of wastes to the environment, a threat to human health or a public nuisance. The Permittee shall
maintain an inspection log that includes, at a minimum, the date and time of inspection, observations
made, and any maintenance, repairs, or corrective actions taken. The Permittee shall maintain this
inspection log for a period of five years from the date of the inspection, and this log shall be made
available to the Division upon request. [15A NCAC 02T .0108(b)]
3. Any duly authorized Division representative may, upon presentation of credentials, enter and inspect
any property, premises or place on or related to the wastewater treatment and irrigation facilities
permitted herein at any reasonable time for the purpose of determining compliance with this permit;
may inspect or copy any records required to be maintained under the terms and conditions of this permit,
and may collect groundwater, surface water or leachate samples. [G.S. 143-215.3(a)(2)]
VI. GENERAL CONDITIONS
1. Failure to comply with the conditions and limitations contained herein may subject the Permittee to an
enforcement action by the Division in accordance with North Carolina General Statutes 143-215.6A to
143-215.6C. [G.S. 143-215.6A to 143-215.6C]
2. This permit shall become voidable if the permitted facilities are not constructed in accordance with the
conditions of this permit, the Division approved plans and specifications, and other supporting
documentation. [15A NCAC 02T .0110]
WQ0030465 Version 2.0 Shell Version 151201 Page 5 of 7

3. This permit is effective only with respect to the nature and volume of wastes described in the permit
application, Division approved plans and specifications, and other supporting documentation. No
variances to applicable rules governing the construction or operation of the permitted facilities are
granted, unless specifically requested and approved in this permit pursuant to 15A NCAC 02T.0 I 05(n).
[G. S. 14.-215.1]
4. The issuance of this permit does not exempt the Permittee from complying with any and all statutes,
rules, regulations, or ordinances, which may be imposed by other jurisdictional government agencies
(e.g., local, state, and federal). Of particular concern to the Division are applicable river buffer rules in
15A NCAC 02B .0200; erosion and sedimentation control requirements in 15A NCAC Chapter 4 and
under General Permit NCG010000; any requirements pertaining to wetlands under 15A NCAC 02B
.0200 and 02H .0500; and documentation of compliance with Article 21 Part 6 of Chapter 143 of the
General Statutes. [15A NCAC 02T .0105(c)(6)]
5. In the event the permitted facilities change ownership or the Permittee changes their name, a formal
permit modification request shall be submitted to the Division. This request shall be made on official
Division forms, and shall include appropriate property ownership documentation and other supporting
documentation as necessary. The Permittee of record shall remain fully responsible for maintaining
and operating the facilities permitted herein until a permit is issued to the new owner. [15A NCAC
02T.0104]
6. The Permittee shall retain a set of Division approved plans and specifications for the life of the facilities
permitted herein. [15A NCAC 02T .0108(b)(1)]
7. The Permittee shall maintain this permit until all permitted facilities herein are properly closed or
permitted under another permit issued by the appropriate permitting authority. [15A NCAC 02T
.01050)]
8. This permit is subject to revocation or unilateral modification upon 60 days notice from the Division
Director, in whole or part for the requirements listed in 15A NCAC 02T.01 10. [ 15A NCAC 02T .0110]
9. Unless the Division Director grants a variance, expansion of the permitted facilities contained herein
shall not be granted if the Permittee exemplifies any of the criteria in 15A NCAC 02T .0120(b). [ 15A
NCAC 02T.0120]
10. The Permittee shall pay the annual fee within 30 days after being billed by the Division. Failure to pay
the annual fee accordingly shall be cause for the Division to revoke this permit. [15A NCAC 02T
.0105(e)(3)]
Permit issued this the 17' day of February 2017
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
�- S. Jay Zimmermann, P.G., Director
Division of Water Resources
By Authority of the Environmental Management Commission
Permit Number WQ0030465
WQ0030465 Version 2.0 Shell Version 151201 Page 6 of 7

Permit No. WQ0030465 Single -Family Residence Wastewater Irrigation System.
Sergio and Norma A. Salazar February 17, 2017
2060 Stewart -Hutchens Rd. SFR Guilford County
ENGINEERING CERTIFICATION
❑ Partial ❑ Final
In accordance with 15A NCAC 02T .0 116, I, as
a duly registered Professional Engineer in the State of North Carolina, having the Permittee's authorization
to ❑ periodically ❑ weekly ❑ fully observe the construction of the permitted facility, hereby state to the
best of my abilities that due care and diligence was used in the observation of the construction, such that
the facility was built within substantial compliance and intent of this permit, the Division approved plans
and specifications, and other supporting documentation.
❑ Any variation to this permit, the Division approved plans and specifications, and other supporting
documentation has been documented in the attached as -built drawings, and shall serve as the
Permittee's minor modification request to amend the permit accordingly.
Provide a brief narrative description of any variations:
THE COMPLETED ENGINEERING CERTIFICATION, INCLUDING ALL SUPPORTING
INFORMATION AND MATERIALS, SHALL BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE PERMITTING UNIT
By U.S. Postal Service: By Courier/Special Delive :
1617 MAIL SERVICE CENTER 512 N. SALISBURY ST.
RALEIGH, NORTH CAROLINA 27699-1617 RALEIGH, NORTH CAROLINA 27604
WQ0030465 Version 2.0 Shell Version 151201
Page 7 of 7

Rd. SFR
. ,
� -
!�W1F1k
t
70"
G00SIC E
D-2016 Google
900 ft
N

State of North Carolina
Department of Environmental Quality
Division of Water Resources
DWR 15A NCAC 02T.0600 — SINGLE -FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEMS
OPERATION AND MAINTENANCE AGREEMENT
Division of Water Resources FORM: SFRWWIS O&M 06-16
Permit No. W 0030465
County: Guilford
Property owner(s) as appearing on the recorded deed: Sergio & Norma A. Salazar
Mailing address: 1547 Andover Ave Greensboro NC 27405
Facility address: 1547 Andover Ave Greensboro NC 27405
Irrigation Method: ❑ SPRAY rh DRIP
I / We agree to operate and maintain the single-family residence wastewater treatment and irrigation system as follows:
1. The Permittee is responsible for the operation and maintenance of the entire wastewater treatment and irrigation
system including, but not limited to, the following items:
a. The septic tank shall be checked annually and pumped out as needed.
b. The septic tank effluent filter shall be checked and cleaned annually.
c. Accessible sand filter surfaces shall be raked and leveled every six months and any vegetative growth shall be
removed manually.
d. [ The tablet chlorinator shall be checked weekly. Wastewater grade tablets (calcium hypochlorite) shall be
added as needed to provide proper chlorination (pool chlorine tablets shall not be used), OR
❑ The ultraviolet disinfection unit shall be checked weekly. The lamp(s) and quartz sleeve(s) shall be cleaned
or replaced as needed to ensure proper disinfection.
e. All pump and alarm systems shall be inspected monthly.
f. The irrigation system shall be inspected monthly to ensure that the system is free of leaks, that all irrigation
equipment is operating as designed, that vegetative growth does not interfere with the system inspection or
operation, that the soil is assimilating the disposed treated wastewater with no visible runoff or ponding, and
that no objectionable odors are being generated.
2. Failure to pay the annual fee shall be cause for the Division to revoke the permit pursuant to 15A NCAC 02T
.0105(e)(3 .
3. The Pennittee's failure to properly operate this system is subject to a penalty up to $25,000 per day.
4. Failure to meet the permit conditions or violation of the State's surface water or groundwater regulations may void
the permit.
All owners ApPearing on the legally recorded Property deed shall sign this O eration & Maintenance Agreement
I / We understand the above requirements and agre o t e terms as part of the issued permit.
Owner Signature: Date:
Owner Signature: C/ Date:
FORM: SFRWWIS O&M 06-16
Page 1 of 1