NCG550144_Permit (Issuance)_20161114

•
r PAT MCCRORY
(an erne!
•
DONALD R. VAN DER VAART
Sec;cirri
Water Resources S. JAY ZIMMERMAN
ENVIRONMENTAL QUALITY
Di eclal
November 14, 2016
Timothy B.Applegate
2605 N Old Greensboro Rd
High Point, NC 27265
Subject: General Permit NCG550000
2605 N Old Greensboro Rd
Certificate of Coverage NCG550144
Davidson County
Dear Permittee:
The Division received your request to renew the subject Certificate of Coverage (CoC). As a result,
the Division hereby,reissues NCG550144. This CoC is issued pursuant to the requirements of North
Carolina General Statue 143-215.1 and the Memorandum of Agreement between North Carolina and the US
Environmental Protection agency dated October 15, 2007 [or as subsequently amended].
If any parts, measurement frequencies or sampling requirements contained in this General 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, the certificate of coverage shall be final and binding.
Please take notice that this Certificate of Coverage is not transferable except after notice to the
Division. The Division may require modification or revocation and reissuance of the certificate of coverage.
Contact the Winston-Salem Regional Office prior to any sale or transfer of the permitted facility.
Regional Office staff will assist you in documenting the transfer of this CoC.
This permit does not affect the legal requirements to obtain any other State, Federal, or Local
governmental permit that may be required. If you have any questions concerning the requirements of the
General Permit,please contact Charles Weaver of the NPDES staff[919 807-6391 or
charle s.we [e-mail]].
erely,
Z.-1
for S. Jay Zimmerman,
Director, Division of Water Resources
cc: Winston-Salem Regional Office
.i IPT!1'ES llg
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.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/npdes-wastewater-permits

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
GENERAL PERMIT NCG550000
CERTIFICATE OF COVERAGE NCG550144
DISCHARGE OF DOMESTIC WASTEWATER FROM SINGLE FAMILY RESIDENCES AND
OTHER 100% DOMESTIC 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,
Timothy B. Applegate
is hereby authorized to discharge <1000 gallons per day of domestic wastewater from a
facility located at -
2605 N Old Greensboro Rd
High Point
Davidson County
to receiving waters designated as an unnamed tributary to Abbotts Creek, a class C stream in
subbasin 03-07-07 of the Yadkin-Pee Dee River Basin in accordance with the effluent limitations,
monitoring requirements, and other conditions set forth in Parts I, II, III and IV hereof.
This certificate of coverage takes effect November 14, 2016.
This Certificate of Coverage shall remain valid for the duration of the General Permit.
Signed this day November 14, 2016
for "' Zimmerman, P.G.
b erector, Division of Water Resources
By Authority of the Environmental Management Commission

1`
AT7A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory Thomas A. Reeder John E. Skvarla, III
Governor Director Secretary
NOTICE OF RENEWAL INTENT
Application for renewal of existing coverage under General Permit NCG550000
Existing Certificate of Coverage (CoC): NCG550 'Lk
(Please print or type)
1) Mailing address of property owner: (address to which all correspondence should be mailed)
Owner Name jL{©j'j APf64T _
Street Address 016) Nb a1 6PFE051304a �r]
City geg, ci07— State IOC, ZIP Code AT26 S'
Telephone# 3___ 6e 7^ `'3 7 Cell#
Fax#
Email Address T4PPC E6°- ,67 C(4 S4 t cOl�
2) Location of facility producing discharge: (If facility is not yet constructed, give street address or lot#)
Street Address
City State ZIP Code
County
Telephone# Cell#
3) Description of Discharge:
a) Is the discharge from(check what applies):
d Primary Residence
❑ Vacation/Second Home
❑ Undeveloped Property
❑ Other(describe):
4) Please check the components that comprise the wastewater treatment system:
a geptio Tank ❑ Dosing Tank o Primary Sand Filter o Secondary Sand Filter
❑ Recirculating Sand Filters ❑ Chlorination ❑ Dechlorination e o Other Form of Disinfection
o Post Aeration(describe):
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NCG500000 Renewal Application
5) Other Information: nn �
a) When was the septic tank last pumped out? iU �l`/ 1 �4&b
NOTE: The septic tank must be pumped out at least once every 3 -5 ears.
b) Is the facility(home) occupied year-round, or only seasonally? Cal Year Round ❑ Seasonal
c) Approximately how many people use the facility when it is occupied?
d) When was the wastewater system installed? '56 I I
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.
Prince e o hi e _ Sit/ g: OW) OPI}Zie6A0C--
(Signature "vplicant) • (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.)
This Notice of Renewal Intent does NOT require a separate fee.
The permitted facility already pays an annual fee for coverage under NCG550000.
Mail this application, one copy of the entire package and a copy of the receipt for your last septic
service to:
NC DENR/DWR/Water Quality Permitting Section
1617 Mail Service Center
Raleigh,North Carolina 27699-1617
Attn: Charles Weaver
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