NCG550097_Permit (Issuance)_19970721

State of North Carolina
Department of Environment,
Health and Natural Resources AT • •
Division of Water Quality
James B. Hunt, Jr., Governor E H N
Wayne McDevitt, Secretary
A. Preston Howard, Jr., P.E., Director July 21, 1997
Samuel J. Hollis
1149 Pine Knolls Road
Kernersville,NC 27284
Subject: Certificate of Coverage No. NCG550097
Renewal of General Permit
Hollis, Samuel J. - Residence
Forsyth County
Dear Permittee:
In accordance with your application for renewal of the subject Certificate of Coverage, the Division is forwarding
the enclosed General Permit. This renewal is valid from the effective date on the permit until July 31,2002. This
permit 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 December 6, 1983. If any
parts,measurement frequencies or sampling requirements contained in this permit are unacceptable to you,you have
the right to request an individual permit by submitting an individual permit application. Unless such demand is
made, this Certificate of Coverage shall be final and binding.
The Certificate of Coverage for your facility is not transferable except after notice to the Division. Use the enclosed
Permit Name/Ownership Change form to notify the Division if you sell or otherwise transfer ownership of the
subject facility. The Division may require modification or revocation and reissuance of the Certificate of Coverage.
If your facility ceases discharge of wastewater before the expiration date of this permit, contact the Regional
Office listed below at [phone]. Once discharge from your facility has ceased, this permit may be rescinded.
This permit does not affect the legal requirements to obtain other permits which may be required by the Division of
Water Quality, the Division of Land Resources, Coastal Area Management Act or any other Federal or Local
governmental permit that may be required.
If you have any questions concerning this permit,please contact the NPDES Group at the address below.
Sincerely,
•
A. Preston Howard,Jr., P.E.
cc: Central Files
Winston-Salem Regional Office
NPDES Group
Facility Assessment Unit
P.O. Box 29535, Raleigh, North Carolina 27626-0535 [phone] FAX [phone] p&[e-mail]
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` • STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCG550000
CERTIFICATE OF COVERAGE NO. NCG550097
TO DISCHARGE DOMESTIC WASTEWATERFROM SINGLE FAMILY RESIDENCES
AND OTHER DISCHARGES WITH SIMILAR CHARACTERISTICS UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision 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,
Samuel J. Hollis
is hereby authorized to operate a wastewater treatment facility which includes a septic tank, sand filter
and associated appurtenances with the discharge of treated wastewater from a facility
located at
Hollis, Samuel J. -Residence
1149 Pine Knolls Road
Kernersville
Forsyth County
to receiving waters designated as subbasin 30201 in the Roanoke River Basin
in accordance with the effluent limitations,monitoring requirements, and other conditions set forth
in Parts I, II, III and IV of General Permit No. NCG550000 as attached.
This certificate of coverage shall become effective August 1, 1997.
This certificate of coverage shall remain in effect for the duration of the General Permit.
Signed this day July 21, 1997.
• 1),-frE.,(, 4.
yelVAPreston Howard, Jr., P.E., Director
.
Division of Water Quality
By Authority of the Environmental Management Commission

• - Letter to SAMUEL J. HOLLIS February 7, 1997
NCG550097
INVOICE FOR RENEWAL OF
NPDES PERMIT - d 3
Check here if you do NOT wish to renew this permit.
Please return this page along with a letter documenting your reasons
for not requesting renewal to:
Mr. Charles H. Weaver, Jr.
Division of Water Quality/WQ Section
NPDES Group
Post Office Box 29535
Raleigh, North Carolina 27626-0535
® Check here if you wish to renew this permit.
Please verify the following information and revise any incorrect entries:
Mailing Address
SAMUEL J.HOLLIS n No revision required.
HOLLIS,SAMUEL J. - RESIDENCE
1149 PINE KNOLLS ROAD
KERNERSVILLE , NC 27284 El
Revision required. (Please specify below.)
Phone number:[phone]
Fax number:( 910) Ct 1' ( l0 1 5
e-mail address:
Facility Location la No revision required.
SAMUEL J.HOLLIS
PINE KNOLLS DEVELOPMENT ❑ Revision required. (Please specify below.)
KERNERSVILLE, NC 27284
Please return this page with your letter requesting renewal, and $240 fee (payable to NCDEHNR) to:
Mr. Charles H. Weaver, Jr.
Division of Water Quality/WQ Section
NPDES Group
Post Office Box 29535
Raleigh, North Carolina 27626-0535
Signature of applicant or authorized representative
Date O 2 1/

r-
Samuel J . Hollis
1149 Pine Knolls Rd.
Kernersville , N. G . 27284
( 910) 996-3355 Home
( 910) 996-7176 Work
February 11 , 1997
State of North Carolina
Department of Environment ,
Health and Natural Resources
Division of Water Quality
Ref : Renewal of NPDES Permit No . NCG 550097
Forsyth County
David A. Goodrich :
I am requesting the renewal of permit number
( NCG 550097 ) . This permit is for property
located at 1149 Pine Knolls Road, Forsyth
County, North Carolina . This is a single
family dwelling.
Attached you will find the check for the
processing fee in the amount of ( $ 240 . 00 ) .
If additional information or assistance is
required please call .
Thank ou ,
amuel J. Hollis