NCG551092_Compliance Evaluation Inspection_20240906

ROY COOPERW ,
Governor 2
ELIZABETH S.BISER may. .. a
RICHARD E.ROGERS,JR. NORTH CAROLINA
Director Environmental Quality
September 6, 2024
Jeremy Vanderwall
1542 Stallings Rd
Durham, NC 27703
Subject: Compliance Evaluation inspection
Single Family Wastewater Treatment System
General NPDES Permit NCG550000
Certificate of Coverage NCG551092
Facility: 1542 Stallings Road, Durham, NC
Durham County
Dear Mr. Vanderwall:
On August 30, 2024, Myles Parker and I from the Raleigh Regional Office visited your single-family
residence(SFR) wastewater treatment system to evaluate compliance with the subject General NPDES
Permit. Your assistance during the inspection was greatly appreciated.
Our records indicate the treatment system consists of a septic tank, sand filter, tablet chlorinator with
chlorine contact chamber, and discharge pipe.
General NPDES Permit NCG550000 and Certificate of Coverage (COC) NCG551092 authorize the
discharge of domestic wastewater from your treatment system to receiving waters designated as Chunky
Pipe Creek (classified WS-IV; NSW) in the Neuse River Basin. The authorized discharge is in
accordance with the effluent limits and monitoring requirements established within the General Permit.
The items below show what conditions were noted at your facility:
Findings during the inspection were as follows:
1. NCG550000 Ownership Change Form: According to Durham County deed of records,
Jeremy Vanderwall owns the residence and property located at 1542 Stallings Road in
Durham, North Carolina. As the property owner, you are also the owner of the existing
single-family wastewater treatment system, which treats the domestic wastewater from the
residence and releases the effluent to the receiving waters indicated above. Because the
treatment system makes an outlet to waters of the state, it is an activity for which the
subject permit is required. To comply with North Carolina General Statute § 143-215.1(a),
which requires a person to obtain a permit to make an outlet into the waters of the state,
you will need to complete and submit the attached NCG550000 Ownership Change Form
to the Division. If you have any questions regarding change in permit ownership or
completing the form, then please contact Myles Parker at 919-791-4236.

Jeremy Vanderwall, NCG551092
September 6, 2024 Page 2 of 3
2. Treatment system operation: The wastewater treatment system shall be maintained at all
times to prevent seepage of sewage to the surface of the ground.
3. Pumping the septic tank: You are required to inspect the septic tank at least yearly to
determine if solids must be removed or if other maintenance is necessary. Septic tanks
should be pumped out every five years or when the solids level is found to be more than
13 of the liquid depth in the septic tank compartment, whichever is greater. A pumping
company can check the status periodically and determine when pumping is required.
During the inspection, you indicated the septic tank had not been pumped out in the last 5
years. Within 30-days of receiving this letter,please send a copy of the most recent
receipdinvoice to this office showing the date the septic tank was last checked and/or
pumped out. The General NPDES Permit requires the permittee to retain records
associated with sewage disposal activities for a period of at least 5 years.
4. Chlorine tablets in the chlorinator: You are reminded that it is required that chlorine
tablets be maintained in the chlorinator to ensure proper disinfection of the discharged
wastewater. Chlorine tablets provide effective disinfection and prevent1imit harmful
bacteria from discharging to the environment. The product label for these tablets must
indicate the tablets are approved for wastewater use and not for swimming ools. Part 1,
Section D (1) of General NPDES Permit NCG550000 requires the pennittee to inspect the
tablet chlorinator weekly to ensure there is an adequate supply of tablets for continuous
and proper operation. Section D (4) requires the permittee to maintain all system
components, including...disinfection units...at all times and in good operating order. The
inspector did not observe any chlorine tablets in the chlorinator. Please ensure the correct
type of tablets are used and maintained in the chlorinator as required by the General
NPDES Permit.
5. Analyzing the effluent: Part 1. C., Effluent Limitations and Monitoring Requirements,
within General Permit NCG550000 requires a permittee to sample and analyze the effluent
leaving his/her treatment system prior to discharge annually. Parameters to be sampled
and analyzed include Flow, BOD (Biochemical Oxygen Demand), Total Suspended Solids,
Fecal Coliform, Total Residual Chlorine, Total Nitrogen, Ammonia Nitrogen and Total
Phosphorous. During the inspection, you informed the inspector that the effluent has not
been monitored within the last 12 months. Please collect a representative sample of the
effluent, have it analyzed by a certified commercial laboratory and submit the results to
this office no later than December 6, 2024. If, during this time, you are unable to collect
a representative sample of the effluent discharge due to insufficient flow from the
discharge pipe, then update this office with that information and continue to monitor the
discharge and if conditions for sampling become favorable, then arrange to collect a
sample. Failure to monitor the effluent discharge as required is a violation of NPDES
General Permit NCG550000.
6. Discharge outlet location. The pennittec is required to conduct a visual review of the
outfall location at least twice each year(one at the time of sampling) to ensure that no
visible solids or other obvious evidence of system malfunctioning is observed. Any visible
signs of a malfunctioning system shall be documented, and steps taken to correct the
problem. The end of discharge pipe was not visible nor accessible the day of the
inspection. To comply with the general pen-nit monitoring requirements, you need to be
if-e- -D Q�p
North Carolina Department of Environmental Quality I Division of Water Resources
Raleigh Regional Office :3800 Barrett Drive Raleigh,North Carolina 27W)
o0�.'ea.semrwta a+u+r� /� 919 741.4200

Jeremy Vanderwall, NCG551092
September 6, 2024 Page 3 of 3
able to sample and analyze the effluent from your SFR system through the discharge pipe.
You need to keep the area around the discharge pipe cleared of vegetation, soil and leaves.
Please take the necessary steps to ensure the discharge outlet is visible and accessible.
Maintaining the area will allow you to monitor the discharge and to collect effluent
samples as required by the subject permit.
Part I1 Section B.14 of General Permit NCG550000 requires the permittee to "pay the annual
administering and compliance monitoring fee within thirty days after being billed by the Division." Once
the permit has been transferred to you, you will receive billing under separate cover.
The wastewater treatment system should be periodically inspected to ensure the treatment components are
always maintained and in good operating order. You are also reminded to maintain all monitoring data
and associated maintenance records onsite for a minimum of three years and available for inspection.
Within 30-days receipt of this letter,please submit a written response to this office indicating the
actions you will take or have taken to comply with or resolve the issues noted items#1, #3, #4, #5, and
#6 above.
If you have questions or comments about this inspection or the requirements to take corrective action (if
applicable), then please contact Myles Parker at 919-791-4236.
Sincerely,
Vanessa E. Manuel, Assistant Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
Attachment(s): EPA Water Compliance Inspection Report
NCG550000 Ownership Change Form
Cc: Laserfiche
North Carolinas Department of Cnvironmenta[Quality Division of Water Resources
Raleigh Regional Office 3800 Barrett Drive Raleigh North Carolina 27600

United Slates Environmental Protection Agency Form Approved.
EPAWashington,D.C.20460 OMB No.2040-0057
Water Compliance Inspection Report Approval expires 8-31-98
Section A:National Data System Coding(i.e., PCS)
Transaction Code NPDES yrlmo/day Inspection Type Inspector Fac Type
1 U 2 15 1 3 1 NCG551092 111 121 24/08/30 117 181 r l 191 S I 20[ I
211111,...11 .1111111111111111 II I I I I I I I I I I I I I I I I I f6
Inspection Work Days Facility Self-Monitoring Evaluation Rating 131 QA --------—-----------Reserved-----------------
67 701 LJ 1 71{ j 72 L�—N ] 73� I L_L_II74 71 1 1 1 1 I I 80
Section B: Facility Data —
Name and location of Facility Inspected(For Industrial Users discharging to POTW,also include Entry Time/Date Permit Effective Date
POTW name and NPDES permit Number) 10:50AM 24/08/30 13/11/20
1524 Stallings Road
Exit Time/Date Permit Expiration Date
1524 Stallings Rd
Durham NC 27703 11:15AM 24/08/30 18/07/31
Name(s)of Onsite Representative(s)fiitles(syPhone and Fax Number(s) Other Facility Data
111
Name,Address of Responsible Official/TitlelPhone and Fax Number
Contacted
Arlen B Cusler,1524 Stallings Rd Durham NC 27703111
No
Section C:Areas Evaluated During Inspection(Check only those areas evaluated)
Permit 0 Operations 8 Maintenar ■ Records/Reports Self-Monitoring Progran
Facility Site Review 0 EffluentlReceiving Wate
Section D: Summary of Finding/Comments(Attach additional sheets of narrative and checklists as necessary)
(See attachment summary)
Name(s)and Signature(s)of Inspector(s) Agency/Office/Phone and Fax Numbers Date
Myles Parker OWR/RRO WQl919-791-4200/
Vanessa E Manu DWR/RR0 WQl919-791-4200/
Signature of anagement Q A Reviewer Agency/Office/Phone and Fax Numbers Date
EPA Form 3560-3(Rev 9-94)Previous editions are obsolete
Page# 1

NPDES yr/mo/day inspection Type (Cont.) 1
31 NCG551092 I11 1 24/08/30 17 18 ICI
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
On August 30, 2024, Myles Parker and I from the Raleigh Regional Office visited your single-family
residence (SFR)wastewater treatment system to evaluate compliance with the subject General
NPDES Permit. Your assistance during the inspection was greatly appreciated.
Our records indicate the treatment system consists of a septic tank, sand filter, tablet chlorinator with
chlorine contact chamber, and discharge pipe.
General NPDES Permit NCG550000 and Certificate of Coverage (COC) NCG551092 authorize the
discharge of domestic wastewater from your treatment system to receiving waters designated as
Chunky Pipe Creek (classified WS-IV; NSW) in the Neuse River Basin. The authorized discharge is in
accordance with the effluent limits and monitoring requirements established within the General
Permit. The items below show what conditions were noted at your facility:
Findings during the inspection were as follows:
1. NCG550000 Ownership Change Form: According to Durham County deed of records, Jeremy
Vanderwall owns the residence and property located at 1542 Stallings Road in Durham, North
Carolina. As the property owner, you are also the owner of the existing single-family wastewater
treatment system, which treats the domestic wastewater from the residence and releases the effluent
to the receiving waters indicated above. Because the treatment system makes an outlet to waters of
the state, it is an activity for which the subject permit is required. To comply with North Carolina
General Statute § 143-215.1(a), which requires a person to obtain a permit to make an outlet into the
waters of the state, you will need to complete and submit the attached NCG550000 Ownership
Change Form to the Division. If you have any questions regarding change in permit ownership or
completing the form, then please contact Myles Parker at 919-791-4236.
2. Treatment system operation: The wastewater treatment system shall be maintained at all times to
prevent seepage of sewage to the surface of the ground.
3. Pumping the septic tank: You are required to inspect the septic tank at least yearly to determine if
solids must be removed or if other maintenance is necessary. Septic tanks should be pumped out
every five years or when the solids level is found to be more than 1/3 of the liquid depth in the septic
tank compartment, whichever is greater. A pumping company can check the status periodically and
determine when pumping is required. During the inspection, you indicated the septic tank had not
been pumped out in the last 5 years. Within 30-days of receiving this letter, please send a copy of
the most recent receipt/invoice to this office showing the date the septic tank was last checked and/or
pumped out. The General NPDES Permit requires the permittee to retain records associated with
sewage disposal activities for a period of at least 5 years.
4. Chlorine tablets in the chlorinator: You are reminded that it is required that chlorine tablets be
maintained in the chlorinator to ensure proper disinfection of the discharged wastewater. Chlorine
tablets provide effective disinfection and prevent/limit harmful bacteria from discharging to the
environment. The product label for these tablets must indicate the tablets are approved for
wastewater use and not for swimming pools. Part 1, Section D (1) of General NPDES Permit
NCG550000 requires the permittee to inspect the tablet chlorinator weekly to ensure there is an
adequate supply of tablets for continuous and proper operation. Section D (4) requires the permittee
to maintain all system components, including...disinfection units...at all times and in good operating
order. The inspector did not observe any chlorine tablets in the chlorinator. Please ensure the
correct type of tablets are used and maintained in the chlorinator as required by the General NPDES
Permit.
5. Analyzing the effluent: Part 1. C., Effluent Limitations and Monitoring Requirements, within
General Permit NCG550000 requires a permittee to sample and analyze the effluent leaving his/her
treatment system prior to discharge annually. Parameters to be sampled and analyzed include Flow,
BOD (Biochemical Oxygen Demand), Total Suspended Solids, Fecal Coliform, Total Residual
Chlorine, Total Nitrogen, Ammonia Nitrogen and Total Phosphorous. During the inspection, you
informed the inspector that the effluent has not been monitored within the last 12 months. Please
collect a representative sample of the effluent, have it analyzed by a certified commercial laboratory
Page# 2

Permit: NCG551092 Owner-Facility: 1524 Stallings Road
Inspection Date: 08/30/2024 Inspection Type: Compliance Evaluation
and submit the results to this office no later than December 6, 2024. If, during this time, you are
unable to collect a representative sample of the effluent discharge due to insufficient flow from the
discharge pipe, then update this office with that information and continue to monitor the discharge
and if conditions for sampling become favorable, then arrange to collect a sample. Failure to monitor
the effluent discharge as required is a violation of NPDES General Permit NCG550000.
6. Discharge outlet location. The permittee is required to conduct a visual review of the outfall
location at least twice each year(one at the time of sampling)to ensure that no visible solids or other
obvious evidence of system malfunctioning is observed. Any visible signs of a malfunctioning system
shall be documented, and steps taken to correct the problem. The end of discharge pipe was not
visible nor accessible the day of the inspection. To comply with the general permit monitoring
requirements, you need to be able to sample and analyze the effluent from your SFR system through
the discharge pipe. You need to keep the area around the discharge pipe cleared of vegetation, soil
and leaves. Please take the necessary steps to ensure the discharge outlet is visible and accessible.
Maintaining the area will allow you to monitor the discharge and to collect effluent samples as
required by the subject permit.
Part II Section B.14 of General Permit NCG550000 requires the permittee to"pay the annual
administering and compliance monitoring fee within thirty days after being billed by the Division."
Once the permit has been transferred to you, you will receive billing under separate cover.
The wastewater treatment system should be periodically inspected to ensure the treatment
components are always maintained and in good operating order. You are also reminded to maintain
all monitoring data and associated maintenance records onsite for a minimum of three years and
available for inspection.
Within 30-days receipt of this letter, please submit a written response to this office indicating the
actions you will take or have taken to comply with or resolve the issues noted items#1, #3, #4, #5,
and #6 above.
Page# 3

Permit: NCG551092 Owner-Facility: 1524 Stallings Road
Inspection Date: 08/30/2024 Inspection Type: Compliance Evaluation
Permit Yes No NA NE
(If the present permit expires in 6 months or less). Has the permittee submitted a new ❑ ❑ M ❑
application?
Is the facility as described in the permit? 0 ❑ ❑ ❑
#Are there any special conditions for the permit? ❑ ❑ M ❑
Is access to the plant site restricted to the general public? ❑ ❑ M ❑
Is the inspector granted access to all areas for inspection? ❑ ❑ ❑
Comment:
Record Keeping Yes No NA NE
Are records kept and maintained as required by the permit? ❑ 0 ❑ ❑
Is all required information readily available, complete and.current? ❑ 0 ❑ ❑
Are all records maintained for 3 years (lab. reg. required 5 years)? ❑ ❑ ❑ 0
Are analytical results consistent with data reported on DMRs? ❑ ❑ 0 ❑
Is the chain-of-custody complete? ❑ ❑ M ❑
Dates, times and location of sampling ❑
Name of individual performing the sampling Cl
Results of analysis and calibration ❑
Dates of analysis ❑
Name of person performing analyses ❑
Transported COCs ❑
Are DMRs complete: do they include all permit parameters? ❑ ❑ ❑
Has the facility submitted its annual compliance report to users and DWQ? ❑ ❑ 0 ❑
(If the facility is =or > 5 MGD permitted flow) Do they operate 24/7 with a certified ❑ ❑ 0 ❑
operator on each shift?
Is the ORC visitation log available and current? ❑ ❑ 0 ❑
Is the ORC certified at grade equal to or higher than the facility classification? ❑ ❑ 0 ❑
Is the backup operator certified at one grade less or greater than the facility ❑ ❑ ❑
classification?
Is a copy of the current NPDES permit available on site? ❑ ❑ ❑
Facility has copy of previous year's Annual Report on file for review? ❑ ❑ 0 ❑
Comment: There has been a change in ownership since the last inspection.
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? ❑ ❑ 0 ❑
Page# 4

Permit: NCG551092 Owner-Facility: 1524 Stallings Road
Inspection Date: 08/30/2024 Inspection Type: Compliance Evaluation
Operations & Maintenance Yes No NA NE
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable ❑ ❑ 0 ❑
Solids, pH, DO, Sludge Judge, and other that are applicable?
Comment:
Septic Tank Yes No NA NE
(If pumps are used) Is an audible and visual alarm operational? ❑ ❑ M ❑
Is septic tank pumped on a schedule? ❑ ❑ ❑
Are pumps or syphons operating properly? ❑ ❑ ■ ❑
Are high and low water alarms operating properly? ❑ ❑ ■ ❑
Comment:
Sand Filters (Low rate) Yes No NA NE
(If pumps are used) Is an audible and visible alarm Present and operational? ❑ ❑ M ❑
Is the distribution box level and watertight? ❑ ❑ ❑
Is sand filter free of ponding? ❑ ❑ ❑
Is the sand filter effluent re-circulated at a valid ratio? ❑ ❑ ❑
# Is the sand filter surface free of algae or excessive vegetation? ❑ ❑ 0 ❑
# Is the sand filter effluent re-circulated at a valid ratio? (Approximately 3 to 1) ❑ ❑ ❑ M
Comment:
De-chlorination Yes No NA NE
Type of system ?
Is the feed ratio proportional to chlorine amount(1 to 1)? ❑ ❑ M ❑
Is storage appropriate for cylinders? ❑ ❑ ■ ❑
# Is de-chlorination substance stored away from chlorine containers? ❑ ❑ M ❑
Comment:
Are the tablets the proper size and type? ❑ ❑ 0 ❑
Are tablet de-chlorinators operational? ❑ ❑ M ❑
Number of tubes in use?
Comment:
Disinfection-Tablet Yes No NA NE
Are tablet chlorinators operational? ❑ ❑ M ❑
Page# 5

Permit: NCG551092 Owner-Facility: 1524 Stallings Road
Inspection Date: 08/30/2024 Inspection Type: Compliance Evaluation
Disinfection-Tablet Yes No NA NE
Are the tablets the proper size and type? ❑ ❑ 00
Number of tubes in use? 2
Is the level of chlorine residual acceptable? ❑ ❑ 0 ❑
Is the contact chamber free of growth, or sludge buildup? M ❑ ❑ ❑
Is there chlorine residual prior to de-chlorination? ❑ ❑ M ❑
Comment:
Effluent Sampling Yes No NA NE
Is composite sampling flow proportional? ❑ ❑ ❑
Is sample collected below all treatment units? ❑ ❑ ❑ 0
Is proper volume collected? ❑ ❑ ❑
Is the tubing clean? ❑ ❑ ❑ ■
# Is proper temperature set for sample storage (kept at less than or equal to 6.0 ❑ ❑ ❑
degrees Celsius)?
Is the facility sampling performed as required by the permit (frequency, sampling type ❑ ❑ ❑
representative)?
Comment:
Effluent Pipe Yes No NA NE
Is right of way to the outfall properly maintained? ❑ M ❑ ❑
Are the receiving water free of foam other than trace amounts and other debris? ❑ ❑ ❑
If effluent (diffuser pipes are required) are they operating properly? ❑ ❑ M ❑
Comment: There was vegetation surrounding the effluent pipe.
Page# 6

Inspection Date: Start Time: d ; SO End Time: '
SINGLE FAMILY WASTEWATER SYSTEM CHECKLIST
1/9/2015 A
c{�+nPermittee: - � Permit: C }!l 9
r tLon-
Address: nos E-mail-
c1"v�n erwal�6 +' a
Phone: - Cell Phone:(qlq ) _- County: Y a
The Permittee is responsible for the operation and maintenance of the entire wastewater treatment and disposal system.
�r Doesn't Did Not
Vayj�e�vv6��
r�— r( rij Pex ^2 Yes No Apply Investigate
1. Is the current resident in the home the Permittee? L1 129 Li Li
v S aGE
2. If not does the resident rent from the permittee? D D /01 ❑
3. Change of Ownership form needed?(mail the form with the inspection letter) ® D D ❑
4. Is there a inspection and maintenance agreement with a contractor? ❑ M ❑ ❑
5. If yes to#4 who is the contractor?
SEPTIC TANK The septic tank and filters should be checked annually and pumped/cleaned as needed.
6. Is all wastewater from the home connected to the septic tank. D ❑ ❑
7. Does the permittee/resident know where the septic tank is located? ❑ D D
8. Has the septic tank been pumped in the last 5 years? D Q ❑ ❑
9. If yes to#8 date, if known If proof, describe
10. Does the septic tank have an EFFLUENT FILTER or SANITARY T? (circle one) unknown
11. If Yes to filter when was the filter cleaned? By whom?
SAND FILTER/TREATMENT PODS YES NO LJ If no proceed to the next section.
Accessible sand filter surfaces shall be raked and leveled every sax months and any vegetative growth shall be removed manually.
12. Is system something other than a sandfilter? ❑ D ❑
13. if yes, what kind?(examples - Peat, Textile, Other or brand name-Advantex, etc.)_
14, Does the permittee know where the sandfilter is located? El � ❑ ❑
15. Does the sandfilter require maintenance? ob .1c�,'2r,s ❑ ❑ ❑ M
If maintenance is required explain in the comment section.
DISINFECTION/ UV YES LJ NO /PSIf no proceed to the next section.
The ultraviolet unit shall be checked weekly.The lamps and sleeves should be cleaned or replaced as needed to ensure proper disinfection
16. Is UV working? D D ❑
17. Has the UV Unit been serviced and bulbs cleaned? ❑ D ❑ 0
18. Who completes the weekly check for the UV?( Non-Discharge)
DISINFECTION 1 TABLETS YES 7J NO If no proceed to the next section.
The tablet chlorinator unit shall be checked weekly to ensure continuous and proper operation, 5e
1 t•�
19, Does the perrittee have the correct chlorine tablets?(If none, mark No) .0 ���,❑ a D
20. Does the Permittee know the location of the chlorinator?A ware 0f11� �❑ ❑
21. Were chlorine tablets observed in the chlorinator? ❑ ❑ ❑
22. Are tablets contacting water? If possible poke them to determine. ❑ ❑ ❑
DECHLOR(Discharge only) YES LJ NO JE If no proceed to the next section.
The dechlorinator unit shall be checked weekly to ensure continuous and proper operation.
23. Does the permittee know where the dechlor is? ❑ ❑ ❑
El
24. Does the permittee have the correct dechlor tablets? ❑ El ❑
25, Were dechlor tablets observed in the dechlorination chamber? 0 ❑ ❑
26. Are tablets contacting water? If possible poke them to determine. ❑ D 11 ❑

J`1C C't SS ivy 2 Doesn't Did Not
Yes No Apply Investigate
PUMP TANK YES LJ NO ^J If no proceed to the next section.
All pump and alarm sytems shall be inspected monthly.(non-discharge)
27. Is the pump working? ❑ ❑ ❑ ❑
28. Are the audible and visual high water alarms operational? ❑ ❑ ❑ ❑
29. Does the permittee know how to check the pump& high water alarm? ❑ ❑ ❑ ❑
30. Last functional test: PUMP AQ DIBLE & VISUAL
DISCHARGE ONLY YES 20 NO If no proceed to the next section.
A visual review of the outfall location shall be executed twice each year(one at the time of sampling to ensure no visible solids or evidence of a malfunction.
31. Does the permittee know where the outfall is located? ❑ ❑ ❑
32. Were you able to locate the outfall? t,4-s v� ' � � L ❑ 0 El- Lm,4 -9�+ . All-2f
33. Is the end of the discharge pipe visible and accessible? 7� �GoL.c, f of El o El
34. Is outlet discharging? �❑j ❑
35. Is right of way maintained around the discharge point? �{{et El El El ❑
36.Any Lab Results available? ❑ ❑ ❑
37. Is there evidence of solids around the discharge point? ❑ ❑ ❑
DRIP or SPRAY YES Ll If no proceed to the next section.
The irrigation system shall be inspected monthly to ensure the system is free of leaks and equipment is operating as designed.
38. Is the system DRIP or IRRIGATION (circle one)? If irrigation number of sprinkler heads.
39. Are the buffers adequate? ❑ ❑ ❑ ❑
40. Is the site free of ponding and runoff? ❑ ❑ ❑ ❑
41. Does the application equipment appear to be working properly? ❑ ❑ ❑ ❑
42. Is there a minimum two wire fence surrounding entire irrigation area? ❑ ❑ ❑ ❑
GENERAL
43.Are the treatment units locked and or secured? ❑ ❑ ❑
44. Has resident had any sewage problems? If yes explain in the comment section ❑ ❑ ❑
45. Does the system match the permit description? If no explain in the comment section ❑ ❑ ❑
46. Is the system compliant? ❑ ❑
47. Is the system failing? If yes,take pictures if possible. ❑ ❑ ❑
48. If system is failing, any sign of children or animals contacting sewage? ❑ ❑
NOD Sent#: - - NOV Sent#: - - -
C ments: Photos Taken? YES ❑ NO
+o s6n� c h d R of nb' 4n thL owneli
e d — e
INSPECTOR: d SIGNATURE.

ROY COOPER
Govetwew
ELIZABETH S-BISER -
Se,relur7
RICHARD E.ROGERS.JR NORTH CARD
ninrn... Environmental Quality
NPDES Certificate of Coverage (CoC)
NCG550000 OWNERSHIP CHANGE FORM
1. Please enter the CoC number for which the change is requested.
Certificate of Coverage
N JCJGJ 5 5 2
il. Please provide the following for the requested change(revised CoC).
a. Request for change is a result of: ❑ Change to ownership of the residence property
❑ Name change of the facility or owner
1'other please explain:
b. CoC will be issued to(person's name
or company name, if applicable):
c. Owner: person legally responsible for
CoC:
First Ml Last
Title
Permit Holder Mailing Address
City State Zip
Phone E-mail Address
d. Facility name(if applicable): 152H 5+A Q$ oQ
e. Facility address: 5 4q l 1;,�t4i dad
Address
L%r�\aPA. gcc 24403
City State Zip
1'. Facility contact person-
[if different from Owner] First MI Last
Phone L-mail Address
ill. Contact person(if different from the person legally responsible for the CoC)
First MI Last
Title
Mailing Address
City State Zip
Phase E-mail Address
\orih Carolum Department of I.rnvtronmcnial Quality I Dev lion of Wwct Resources
DEQ2S 512 North Salisbury-S1reLt I Ibi 7 Ntail Scntce Cmit7 I Raleigh.North Carolina 27499-1617
�/ 419,707 9000
�.c.m.m.,e r„rMnraw+w..r, rr/

Page 2 of 2
Will this permitted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change?
❑ Yes
❑ No(please explain)
` Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both facility-name change and/or facility ownership
change requests.
❑ Legal documentation of the transfer of ownership(such as a property deed,relevant pages of a
contract,or a bill of sale) is required for an ownership change request.
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The certifications below must be completed and signed by the new applicant in the case of an ownership
change request.
APPLICANT CERTIFICATION
1, , attest that this application for a name,ownership change has been reviewed and is accurate and
complete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting information is not included, this application package will be
returned as incomplete-
Signature Date
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PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Mr. Charles H. Weaver
NC DEQ/DWR NPDES
1617 Mail Service Center
Raleigh,NC 27699-1617
[e-mail]