WQ0013205_NOD-2019-PC-0114_20190510

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
NORTH CAROLINA
Environmental Quality
May 10, 2019
JARRETT R. ALBRIGHT AND JESSICA R. ALBRIGHT
641 Hoy LONG ROAD
WINSTON-SALEM, NORTH CAROLINA 27107
Subject: Notice of Deficiency
NOD-2019-PC-0114
Permit No. WQ0013205
641 Hoy Long Rd. SFR
Single -Family Residence
Wastewater Irrigation System
Davidson County
Dear Mr. and Mrs. Albright:
It has come to the Division of Water Resources' attention that the subject single-family residence
wastewater irrigation facility has changed ownership. The Davidson County Register of Deeds indicates
that Jarrett R. Albright and Jessica R. Albright purchased the subject property (Parcel No.
1302800000014A) from James Steven Summer and Rhonda N. Summer on July 27, 2017 (Deed Book:
2278 / Page: 674).
The wastewater treatment and irrigation system associated with this property are covered under an
individual State -issued non -discharge permit (Permit No. WQ0013205). Accordingly, please complete and
submit the attached Non -Discharge Permit Ownership/Name Change application (Form: NDPONC) and
the Single -Family Residence Wastewater Irrigation System Operation and Maintenance Agreement (Form:
SFRWWIS O&M). These forms have 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 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
nathaniel.thornburgtQ7ncderingov.
Sincerely,
Nathaniel D. Thornburg, Branch Chie
Division of Water Resources
North Carolina Department of Environmental Quality I Division of Water Resources
0-1
512 North Salisbury Street 1 1617 Mail Service Center I Raleigh, North Carolina 27699-1617
NOF7IN CRROLINA J� v
r 919.707.9000

cc: Winston-Salem Regional Office, Water Quality Regional Operations Section (Electronic Copy)
Laserfiche File (Electronic Copy)
Central Files

State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
NON -DISCHARGE PERMIT OWNERSHIP/NAME CHANGE
Division of Water Resources INSTRUCTIONS FOR FORM: NDPONC 06-16 & SUPPORTING DOCUMENTATION
This form is for ownership changes or name changes of a non -discharge system permit. Please note that "Permittee"
references the existing permit holder, and that "Applicant" references the entity applying for the ownership/name change.
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit website
A. Non -Discharge Permit Ownership/Name Change (FORM: NDPONC 06-16) Application (All Applications):
❑ Submit an original completed and appropriately executed Non -Discharge Permit Ownership/Name Change (FORM: NDPONC
06-16) application.
❑ The Existing Permittee's Certification shall be signed in accordance with 15A NCAC 02T .0106(b). Per 15A NCAC 02T
.0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from a person who
meets the criteria in 15A NCAC 02T .0106(b ).
❑ The Applicant's Certification shall be signed in accordance with 15A NCAC 02T .0106(b_ ). Per 15A NCAC 02T .0106(c). an
alternate person may be designated as the signing official if a delegation letter is provided from a person who meets the criteria
in 15A NCAC 02T .0106 .
B. Existing Permit (All Applications):
❑ Submit a copy of the most recently issued permit.
C. Property Ownership Documentation (All Applications):
➢ Per 15A NCAC 02T .0504(f), 15A NCAC 02T .0604(e), 15A NCAC 02T .0704(f), 15A NCAC 02T .0804, 15A NCAC 02T
.1004(d), 15A NCAC 02T .I104(d)(7), 15A NCAC 02T .1104(e)(5), 15A NCAC 02U .0201(e} or 15A NCAC 02U .0202(f),
the Applicant shall demonstrate they are the owner of all property containing the non -discharge system facilities:
❑ Legal documentation of ownership (i.e., GIS, deed or article of incorporation), or
❑ Written notarized intent to purchase agreement signed by both parties with a plat or survey map, or
❑ 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. Lease agreements shall adhere to the requirements of 15A NCAC 02L .0107.
D. Certificate of Public Convenience and Necessity (All Applications where the Applicant is a Privately -Owned Public Utility):
❑ Per 15A NCAC 02T .0115(a)( I , provide one copy of the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served
by the non -discharge system.
E. Operational Agreements (All Applications where the Applicant is a Home/Property Owners' Association or Developer of lots to
be sold):
➢ Home/Property Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit an original properly executed Operational Agreement FORM: HOA .
❑ Per 15A NCAC 02T .0115(c), submit an original proposed or approved Articles of Incorporation, Declarations and By-
laws.
➢ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit an original of the properly executed Operational Agreement (FORM: DEV
F. Operation and Maintenance Agreement (All Applications for Single -Family Wastewater Irrigation Systems):
❑ Per 15A NCAC 02T .0604(h), submit an original of a notarized O eration and Maintenance Agreement FORM: SFRWWIS
O&M) that has been signed and dated by all deeded property owners.
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED TO:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE BRANCH
By U.S. Postal Service:
1617 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1617
By Courier/Special Delivery:
512 N. SALISBURY ST.
RALEIGH, NORTH CAROLINA 27604
TELEPHONE NUMBER: [phone]
INSTRUCTIONS FOR FORM: NDPONC 06-16 & SUPPORTING DOCUMENTATION Page 1 of 1

State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
NON -DISCHARGE PERMIT OWNERSHIP/NAME CHANGE
D1vislon of Water Resources FORM: NDPONC 06-16
I. EXISTING PERMITTEE INFORMATION:
1. Permittee's name: David A. Freeman
2. Signature authority's name: David A. Freeman per 15A NCAC 02T .0106(b) Title: Owner
3. Permittee's mailing address:
City: State: Zip: -
4. Permittee's contact information: Phone number: (_) _- Email Address:
5. Demonstration of historical consideration for permit approval — 15A NCAC 02T .0120:
Has the Permittee or any parent, subsidiary or other affiliate exhibited the following?
a. Has been convicted of environmental crimes under Federal law or G.S. 143-215.6B? ❑ Yes or ❑ No
b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or ❑ No
c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes or ❑ No
d. Is non -compliant with an existing non -discharge permit, settlement agreement or order? ❑ Yes or ❑ No
e. Has unpaid annual fees in accordance with 15A NCAC 02T .0105(e)(2)? ❑ Yes or ❑ No
II. FACILITY INFORMATION:
1. Facility name: 641 Hoy Long Rd. SFR
2. Facility's physical address: 641 Hoy Long Road
City: Winston-Salem State: North Carolina Zip: 27107- County: Davidson
III. PERMIT INFORMATION:
1. Existing permit number: WQ0013205 and most recent issuance date: December 1. 2014
2. Existing permit type: Single -Family Residence Wastewater Irrigation
3. Reason for the permit application: Change of Ownership
4. Has the facility been constructed? ® Yes or ❑ No
IV. APPLICANT INFORMATION:
1. Applicant's name: Jarrett R. Albrigbt and Jessica R. Albr' ht
2. Signature authority's name: Jarrett R. Albright and Jessica R. Albright per 15A NCAC 02T .0 10h Title: owners
3. Applicant's mailing address: 641 Hoy Long Rd.
City: Winston-Salem State: North Carolina Zip: 27107-
4. Applicant's contact information: Phone number: (__) _- Email Address:
5. Demonstration of historical consideration for permit approval — 15A NCAC 02T .0120:
Has the Applicant or any parent, subsidiary or other affiliate exhibited the following?
a. Has been convicted of environmental crimes under Federal law or G.S. 143-215.6B? ❑ Yes or ❑ No
b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or ❑ No
c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes or ❑ No
d. Is non -compliant with an existing non -discharge permit, settlement agreement or order? ❑ Yes or ❑ No
e. Has unpaid annual fees in accordance with 15A NCAC 02T .0105(e)(2)? ❑ Yes or ❑ No
FORM: NDPONC 06-16 Page 1 of

Existing Permittee's Certification per 15A NCAC 02T .0106(b):
I,
(Signature Authority's name & title from Application Item I.2.)
(Facility name from Application Item II.1.)
attest that this application for
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that prior to reissuance of the permit
into the Applicant's name, any discharge of wastewater from this non -discharge system to surface waters or the land will result in an
enforcement action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the
Division of Water Resources should a condition of the existing permit be violated. I also 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 that the existing Permittee or any affiliate has not been convicted of an
environmental crime, has not abandoned a wastewater facility without proper closure, does not have an outstanding civil penalty where
all appeals have been exhausted or abandoned, are compliant with any active compliance schedule, and do not have any overdue annual
fees per 15A NCAC 02T .0105(e).
NOTE — In accordance with General Statutes 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
Applicant's Certification per 15A NCAC 02T .0106(bl:
I,
Date:
(Signature Authority's name & title from Application Item IV.2.)
(Facility name from Application Item I1.1.)
attest that this application for
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that after reissuance of the permit
into the Applicant's name, any discharge of wastewater from this non -discharge system to surface waters or the land will result in an
enforcement action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the
Division of Water Resources should a condition of this permit be violated. I also 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 to me as incomplete. I further certify that the Applicant or any affiliate has not been convicted of an environmental
crime, has not abandoned a wastewater facility without proper closure, does not have an outstanding civil penalty where all appeals have
been exhausted or abandoned, are compliant with any active compliance schedule, and do not have any overdue annual fees per 15A
NCAC 02T .0105(e).
NOTE — In accordance with General Statutes 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:
FORM: NDPONC 06-16 Page 2 of 2

State of North Carolina
Department of Environment and Natural Resources
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 08-13
Permit No. WQ0013205
County: Davidson
Property owner(s) as appearing on the recorded deed: Jarrett R. Albright and Jessica R. Albright
Mailing address: 641 Hoy Long Rd., Winston Salem NC 27107
Facility address: 641 Hoy Long Rd., Winston Salem NC 27107
Irrigation Method: ® SPRAY ❑ 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 Permittee'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 prol)ertv deed shall sign this Operation & Maintenance Agreement
I / We understand the above requirements and agree to these terms as part of the issued permit.
Owner Signature:
Owner Signature:
Date:
Date:
FORM: SFRWWIS O&M 08-13 Page 1 of 1