NCG550527_owner name change_20171228

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Interim Director
Water Resources
ENVIRONMENTAL QUALITY
December 28, 2017
Yunus S. Budhisetiawan
4446 Redfern Place
Winston-Salem, NC 27107
Subject: NPDES General Permit NCG550000
Transfer of NCG550527
4036 Langden Road
Forsyth County
Dear Permittee:
The Division hereby transmits Certificate of Coverage (CoC) NCG550527, issued under
NPDES General Permit NCG550000. This action is taken to show that you are now the
owner of the subject facility. This CoC is issued pursuant to the requirements of North
Carolina General Statute 143-215.1 and the Memorandum of Agreement between North
Carolina and the U.S. Environmental Protection Agency dated October 15, 2007 (or as
subsequently amended).
If any parts, measurement frequencies or sampling requirements contained in the
General Permit are unacceptable to you, you have the right to request an individual NPDES
permit upon written request within thirty (30) days following receipt of this letter. Unless
such a request is made, this transfer of the subject CoC shall be final and binding.
This CoC is not transferable except after notice to the Division. The Division may
require modification or revocation and reissuance of the CoC. This permit does not affect the
legal requirements to obtain other permits which may be required by any other Federal,
state, or local government. If you have any questions concerning this matter, please contact
Emily Phillips at [phone] or via e-mail [[e-mail]].
incerely,
�f
Linda Culpepp
Interim Director
cc: Winston-Salem Regional Office
NPDES files
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh, NC 27699-1617
919 807 6300 919-807-6389 FAX
https://deq.nc.govlabout/divisions/water-resources/water-resources-permits/wastewater-branchlnpdes-wastewater-permits

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
CERTIFICATE OF COVERAGE NCG550527
Under GENERAL PERMIT NCG550000
TO DISCHARGE 100%-DOMESTIC AND SIMILAR WASTEWATERS UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
(NPDES)
In compliance with the provisions of North Carolina General Statute 143-215.1, other lawful
standards and regulations promulgated and adopted by the North Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended,
Yunus S. Budhisetiawan
are hereby authorized to operate a wastewater treatment facility with a discharge of < 1000
gallons per day); discharging from
4036 Langden Road
Winston-Salem
Forsyth County
to receiving waters designated as an unnamed tributary (UT) to South Fork Muddy Creek
[stream segment 12-94-13 a waterbody currently classified C located within sub -basin
03-07-04 of the Yadkin Pee -Dee River Basin, in accordance with the effluent limitations,
monitoring requirements, and other conditions set forth in Parts I, II, and III of General
Permit NCG550000 as attached.
This certificate of coverage shall become effective December 28, 2017.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day December 28, 2017. ;
da Culpepper
Interim Director, Division of Water Resources
By Authority of the Environmental Management Commission

State of North Carolina
Department of Environment,
Health and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
M±M ±1W
won,
C)EHNR
WATER QUALITY SECTION
PERMIT NAME/OWNERSHIP CHANGE FORM
r��._,_� •ter .• .,
Permit Number: NCG55/ v / 5/ 2/%/
7
1. Permit holder's name: � JGI�/y1/S
2. Permit's signing official's name and
legally responsible for permit)
%% (Title)
3. Mailing address. `J O „ .,2,4 e City: "'Z.V /0 /f
State: NC' Zip Code: 27Zf s Phone:
II. NEW OWNIE 4AME INFORMATION• RECEIVED/DLNR/DWR
1. This request for a name change is a result of: DEC IS 2017
__V_/a. Change in ownership of property /company
Water Resources
b. Name change only Permitting Sectiart
C. Other (please explain):
2. New owner's name (name to be put on permit): X, f, I Q
3. New owner's or signing official's name and title:_
(Person legally responsible for permit)
/h t
'S.: •(. 4i ill '�: f `��.._
(Title)
4. Mailing address: i'r_:i—f Intl) (C City: t. C I-r\..
State: Zip Code: 27b, Phone: (1,11)_
P.O. Box 29535' Raleigh, North Carolina 27626-0535 Telephone [phone] fAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled / 10% post -consumer paper

4446 Redfern Place
Cynthia D. Budhise tiawan Winston-Salem, N7
2710
704-796-1755
[e-mail]
December 4th, 2017
Dear Mr. Joe Corporon,
I want to thank you for your assistance in the matter of getting our permit-. #NCG550527
reconciled.
Enclosed you will find a check in the amount of $120.00 to apply to 2016 and 2017 annual fees
along with a copy of the transfer of ownership form that was filled out at the time of
purchasing the land.
As mentioned in our telephone conversation earlier today, we do not plan on building on the
property anytime soon, and in actuality, we are planning on using it as an off -grid home base in
the coming years for when we retire and travel our beautiful country in an RV.
If there is any other information you may have for or from us please don't hesitate to contact
either my husband (Yunus S. Budhisetiawan) or myself.
Thank you for your time and consideration..
Sincerely,
Cynthia Budhisetiawan
a/k/a Cyndi Budhi