NCG551168_application_20020207

North Carolina Department of Environment and Natural Resources
Division of Water Quality
RENEWAL FORM FOR EXISTING PERMITTED FACILITIES
NPDES renewal application for continued coverage under General Permit NCG550000:
Certificate of Coverage NCG551168
(Please verify the information in items 1 & 2 as correct, or note any corrections that should be made.)
(Please print or type all other answers)
1) Mailing address* of property owner:
Owner Name Donald L Brown /
Street Address 3114 NC Hwy 150
Address Reidsville, NC 27320
Telephone (Home) '336 3 /4- '`/4- '% (Mobile)
(e-mail address)
Address to which all permit correspondence will be mailed
2) Location of facility producing discharge*:
Facility ID Donald L Brown - SFR
Address: Beaver Lodge Cir,
Reidsville, NC 27320 (Rockingham County)
Telephone (Home) (Mobile)
If the facility is not yet constructed, give the street address or lot number where the structure will be
built.
3) Description of Discharge:
a) Type of facility producing waste (please check one):
❑ Primary residence
O Vacation/second home
❑ Undeveloped property
O Other [describe]:
4) Please check the components that comprise the wastewater treatment system:
O Septic tank 0 Dosing tank ❑ Primary sand filter 0 Secondary sand filter
O Recirculating sand filter(s) 0 Chlorination 0 Dechlorination
O Other form of disinfection: 0 Post Aeration (describe)
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NCG550000 renewal form
5) Other Information:
a) When was the septic tank last pumped out?
NOTE: the septic tank must be pumped out at least once every 3-5 years
b) Is the facility [home] occupied year-round, or only seasonally?
c) Approximately how many people use the facility when it is occupied?
d) When was the wastewater system installed?
6) Certification:
I certify that I am familiar with the information contained in this application and that to the best of my
knowledge and belief such information is true, complete, and accurate.
Printed Name of Person Signing: 1 J &Nia1 L ' -6 R.0 Ltd
�- o 7
(Signature of Applicant) (Date Signed)
North Carolina General Statute 143-215.6 b (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any
application, record, report, plan or other document filed or required to be maintained under Article
21 or regulations of the Environmental Management Commission implementing that Article, or who
falsifies, tampers with or knowingly renders inaccurate any recording or monitoring device or
method required to be operated or maintained under Article 21 or regulations of the Environmental
Management Commission implementing that Article, shall be guilty of a misdemeanor punishable
by a fine not to exceed $25,000, or by imprisonment not to exceed six months, or by both. (18 U.S.C.
Section 1001 provides a punishment by a fine of not more than $25,000 or imprisonment not more
than 5 years, or both, for a similar offense.)
Mail this completed form and a copy of the receipt for your last septic service to:
Mr. Charles H. Weaver, Jr.
NC DENR / DWQ / NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
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