NCG550203_Compliance Evaluation Inspection_20180122

3
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Water Resources
Environmental Quality
Mr. Adam Howard Lewis
2000 Piney Grove Road
Kernersville, NC 27284
January 22, 2018
Subject: Compliance Evaluation Inspection
Certificate of Coverage: NCG550203
2000 Piney Grove Road, Kernersville
Forsyth County
Dear Mr. Lewis:
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Interim Director
SAN 30 2018
Water ResourCeS
i'er"tting Section
On January 11, 2018, Jenny Graznak of this office conducted a compliance evaluation inspection
on the wastewater discharge system located at the above address. The State requires the Division
of Water Resources to inspect these types of systems every five years. According to county
records, you are the current owner of this property, but no one appeared to be home during the
inspection. Ms. Graznak was unable to reach you via telephone because our office does not have
a phone number on file for you.
According to our files, the system includes a septic tank, a sub -surface sand filter system,
chlorination unit, and discharge pipe. Ms. Graznak did not locate the discharge pipe during her
inspection. Please be aware that the Permit requires that the chlorinator be adequately supplied
with chlorine tablets for proper operation. The Permit also requires that the septic tank contents
be pumped out every 5 years to prevent solids from clogging the sand filter system.
A copy of all the Permit requirements, including monitoring requirements, is attached to this
letter. Please contact Ms. Graznak at [phone] to discuss your wastewater system and to
make sure we have an accurate phone number on file.
CC: WSRO Files
NPDES Unit
Sincerely,
4L
Sherri V. Knight, P.E., Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources
5,—Nothing Compares '_-_ ..
State of North Carolina I Environmental Quality
450 W Hanes Mill Road, Suite 300, Winston-Salem, North Carolina 27105
Phone [phone] FAX [phone]

Permit- NCG550203
Inspection Date- 01/11/2018
Permit
Owner - Facility 2000 Piney Grove Road
Inspection Type- Compliance Evaluation
(If the present permit expires in 6 months or less) Has the permittee submitted a new
application?
Is the facility as described in the permit?
# Are there any special conditions for the permit?
Is access to the plant site restricted to the general public?
Is the inspector granted access to all areas for Inspection?
Comment:
Yes No NA NE
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r

United States Environmental Protection Agency
Form Approved
EPA Washington, 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 yr/mo/day Inspection Type
Inspector Fac Type
1 IN I 2 Is I 3 I NCG550203 111 12 18/01/11 17
18 I r• I
19 [±j 20I
21111111111111111111111111111111111111111111166
I
Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 QA
Reserved
67 701 I 71 I I 72 I N I
L_J I—I
731 I 174 75 80
I I I
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)
01 OOPM 18/01/11
13/08/01
2000 Piney Grove Road
Exit Time/Date
Permit Expiration Date
2000 Piney Grove Rd
01 30P 18/01/11
18/07/31
Kemersville NC 27284
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
Other Facility Data
///
Name, Address of Responsible Official/Title/Phone and Fax Number
Contacted
Adam H Lewis,2000 Piney Grove Rd Kernersville NC 27284///
No
Section C Areas Evaluated During Inspection (Check only those areas evaluated)
Permit
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
Jennifer F Graznak WSRO WQ//336-771-5000/
/�
)
�/( lig✓ O
Signature of Management Reviewer Agency/Office/Phone and Fax Numbers
Date
�QjA
6
. ice Y , '(1 4
i i G. Z-( i
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete
Page#

NPDES yr/mo/day Inspection Type (Cont) 1
31 Ncc550203 I11 1218/01/11 1 A 18
Section D Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
On January 11, 2018, Jenny Graznak of this office conducted a compliance evaluation inspection on
the wastewater discharge system located at the above address The State requires the Division of
Water Resources to inspect these types of systems every five years. According to county records, you
are the current owner of this property, but no one appeared to be home during the inspection. Ms.
Graznak was unable to reach you via telephone because our office does not have a phone number on
file for you.
According to our files, the system includes a septic tank, a sub -surface sand filter system, chlorination
unit, and discharge pipe. Ms. Graznak did not locate the discharge pipe during her inspection Please
be aware that the Permit requires that the chlorinator be adequately supplied with chlorine tablets for
proper operation The Permit also requires that the septic tank contents be pumped out every 5 years
to prevent solids from clogging the sand filter system
Page#