NCG551766_Application_20191028

National Pollutant Discharge Elimination System FOR AGENCY USE ONLY
(NPDES)
} Date Received
Division of Water Resources
Application for SURFACE DISCHARGE Year Month Day
Enva w nentat Certificate of Coverage (COC) Under aCri 10 ag
Quality General Permit NCG550000 Certificate of Coverage(COC)
For Single-Family Residences and Similar Discharges N C G 5 5 ) -7 (Q 6,
100%-domestic wastewater-<1,000 gallons per day Check# Amount
i31 L1(Wo.
Assigned to:
The Division of Water Resources will not accept an application package unless all instructions are followed.
Failure to submit all required items may result in the application being returned. For more information, visit
the Water Quality Permitting Section's NPDES Permitting Unit website. (Press TAB to navigate form)
1. Regional Office Contact: Please contact your DWR Regional Office before submitting this
application. If you have not met with your appropriate DWR Regional Office Representative,the
application will be returned.
Please list the DWR Regional Office representative(s)with whom you have discussed this project:
Name(s): Jane Bernard Date: 10/25/2019
2. Owner's Contact Information:
Applicant Type: ® Individual ❑ Corporation ❑ Partnership
Owner Name and Title: Land Owner
Street Address: 1204 Goodwin Road
City: Durham State: NC Zip: 27712 -
Telephone#(H): Telephone#(W):
Cell/Mobile#: [phone] Email: smorganlla @yahoo.com
3. Location of Facility Producing the Discharge: Please list the address of the facility. If facility is not yet
constructed,give street address or lot number.
Street Address: 1204 Goodwin Road
City: Durham State: NC Zip: 27712 -
County: Durham
Telephone#: Cell/Mobile#: [phone]
Website:
4. Site-Location Narrative:
Please describe how to get to the facility from the nearest town,major highway or identifiable roadway
intersection(use street names, state road numbers,and/or distances and directions).
Click here to enter text.
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Application for Certificate of Coverage (COC) and/or Authorization to Construct(ATC)
under General-Permit NCG550000
5. Describe the nature of the project. ["New"means has not yet been physically constructed, "existing"
means system already physically exists. Please see 15A NCAC 02H.0103(11) for further clarification].
❑ Installation of a New Wastewater Treatment System(Ifyes, skip to Number 9.)
® Existing,unpermitted Sandfilter Discharging System
❑ Expansion of an Existing Wastewater Treatment System(for example,adding bedrooms) (Ifyes,
skip to Number 9.)
❑ Replacement of an Existing Wastewater Treatment System(Ifyes, go to Number 6.)
6. Describe the Existing Wastewater Treatment System:
❑ Conventional Septic Tank/Leach-field—Discharge to Sub-Surface Soils. If previously permitted,
please attach a copy of the permit or enter the permit number
If you are not aware of an existing permit, check here. ❑
• Sandfilter—Discharge to Surface Waters [or other,as defined 15A NCAC 02H.0103(11)1. If
previously permitted,please attach a copy of the permit or enter the permit number
If you are not aware of an existing permit,check here. El
❑ Filter Media System(Pod System)—Discharge to Surface Waters [or other, as defined 15A NCAC
02H.0103(11)]. If previously permitted,please attach a copy of the permit or the permit number.
If you are not aware of an existing permit,check here. ❑
❑ Other
❑ Check here if submitting proposal for a new system or if no treatment system exists.
7. Check all EXISTING wastewater treatment components:
® Septic tank ❑ Dosing tank n UV disinfection
® Primary sand filter ❑ Secondary sand filter n Recirculating sand filter(s)
® Chlorination ® Dechlorination Other components:
❑ Self-Contained POD system [describe]
❑ Leach Field
❑ Post Aeration (sped type)
8. Provide Details of Single-Family Residence(SFR) or Similar Facility:
a) Type of facility:
®Residential ❑ Commercial
❑Other:
b) Amount of wastewater discharged:
- Residential:Number of bedrooms 3 x 120 gallons per bedroom= 360
gallons per day(flow)
- Commercial: How many employees?(25 gpd/person)
Page 2 of 7 Revised:A. Orlando NPDES 21Sept2017

Application for Certificate of Coverage (COC) and/or Authorization to Construct(ATC)
under General-Permit NCG550000
c) Is your existing treatment system failing? Yes ❑ No
d) Has the Health Department formally condemned your existing system
"unsuitable for repair?" Yes ❑ No ❑
If yes,please name the Health Department [local,county,or state],and provide the site-
inspection date [attach Health Department's judgement letter, if available]: Click here to enter
text. Click here to enter a date.
X_If previously permitted [local, county, or state],provide permit number and date issued [attach
copy, if available]: Durham County Permit#4576
9. Check all PROPOSED new system components
❑ Septic tank ❑Dosing tank ❑ UV disinfection:
❑ Primary sand filter ❑ Secondary sand filter ❑ Recirculating sand filter(s)
❑ Chlorination ❑ Dechlorination ❑ Other components:
❑ Self-Contained POD system [describe]
❑ Post Aeration(sped type)
❑ Proposed Modifications to Existing Treatment System-Explain in detail the nature of the
modification.Attach all site maps,plans and specifications, signed by an NC Certified Engineer.
If prepared by others,plans must conform to 15A NCAC 02H .0139.
Click here to enter text.
❑ Proposed New Treatment System for Surface Discharge(not constructed)-Attach all site maps,
plans and specifications,to be signed by an NC Certified Engineer. If prepared by others,plans
must conform to 15A NCAC 02H .0139.
Click here to enter text.
Expanding Flow?-Do you propose to increase permitted or existing flow? ❑Yes ❑ No
Provide details of the Proposed NEW Discharge [Flow and Source Water]:
❑ Check if same as 6.
Existing: Amount of wastewater currently discharged: Number of bedrooms x 120
gallons per bedroom= gallons per day to be permitted(design flow)
Expanding: Amount of wastewater proposed to be discharged:Number of bedrooms x
120 gallons per bedroom= gallons per day to be permitted(design flow
10. Evaluate Alternatives to Discharge to Waters of the State.Please address the feasibility of
discharge alternatives as instructed in the NCDEQ Engineering Alternatives Analysis(EAA)
Guidance Document found here. (Note:Evaluation for endangered species is not required.)
Page 3 of 7 Revised:A. Orlando NPDES 21Sept2017

Application for Certificate of Coverage (COC) and/or Authorization to Construct (ATC)
under General-Permit NCG550000
a) Connection to an Existing Wastewater Treatment System-Provide the distance
to the nearest connection, such as a regional or municipal sewer system, and the
estimated cost per foot to connect including fees. Click here to enter text.
b) Land Application—Assess the land application disposal alternatives such as spray
irrigation,drip irrigation, individual/community onsite subsurface systems,and/or
innovative ground-absorption. Questions to consider:
(1) Are on-site soils suitable for land application? Yes ❑ No
(2) Is there sufficient area on-site? Yes ❑ No
c) Wastewater Reuse—Evaluate reusing all or a portion of the wastewater
generated, such as for golf course irrigation,crop irrigation(e.g.,hardwood or
pine plantation, grasses), athletic field irrigation, landscape uses,and/or
commercial/industrial uses.
d) On-Site Soil Evaluation—Submit an evaluation of the soils on-site,
documented by a certified report from a NC Professional Soil Scientist, or by
your local or county health department report(if available).Click here to enter
text.
e) Cost of Alternatives—Provide an estimation of the cost of each discharge
alternative or combination of alternatives. Click here to enter text.
11. Provide Regional Information: Please provide the following information. If you need assistance in
obtaining this information,please contact your local DEQ regional office.
a) Stream Classification-Verify the stream classification for the nearest downgradient named
waterbody. The NC Surface Water Classification map can be found by clicking here.
b) Is it a High-Quality Water?If so,check if it is by definition or by designation?In order to check
this, ask the Planning Unit.
Click here to enter text.
c) Map-Provide a map locating the nearest downstream waters-of-the-State(i.e. where the effluent
reaches an unnamed tributary, creek, stream,river,or lake via any surface-water conveyance).
Click here to enter text.
d) Site Evaluation-Contact DEQ's local Regional Office for a site evaluation to confirm the
proposed discharge flow path to the nearest waters-of-the-State.The wastewater/stream
confluence and stream class must be verified in the field by DEQ's Regional Staff. Please list the
Regional Office staff member you contacted for the inspection.Jane Bernard
e) Flow Path-Display graphically the flow path of the discharge to the nearest surface Waters of
the State. Document any potential hydrologic trespass or right-of-way infringement on any
neighboring property(i.e.note all properties encountered prior to reaching waters-of-the-State).
No potential hydrologic trespass
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Application for Certificate of Coverage (COC) and/or Authorization to Construct (ATC)
under General-Permit NCG550000
f) 7010/3002 Estimate-Contact USGS J. Curtis Weaver(919-571-4043)to provide the estimated
7Q10 and 30Q2 stream-flow estimates for the first downstream point-of-contact with waters-of-
the-State.
•
11. Certificates of Coverage/Notices of Intent to Discharge/Authorizations to Construct-Check ALL of
the following information has been provided. Incomplete Applications will be returned.
® An original letter [two(2)copies]requesting coverage under NCG550000.
® This application [two(2)copies]. Your signature on this application, certifies that you are legally
responsible for the proposed treatment system (see page 6 of 6)for the COC/NOI/ATC.
® A check or money order for$60.00 permit fee made payable to NCDEQ.
12. Additional Application Requirements
a) Narrative Description of the treatment system. This narrative should present treatment components
in order of flow—influent to outfall, including anti-erosion structures and sample-port location(s).
b) Final Plans and Specifications for a wastewater treatment system shall be signed by a North
Carolina-registered Professional Engineer,or if prepared by others,must conform to 15A NCAC
02H.0139. All_documents are to be stamped "Final Design-Not Released for Construction."
Submittal shall include a site map showing the proposed outfall and the effluent proposed path to
surface waters-of-the-State.(see Item 1 for location verification by DWR Regional Office staff)
c) Submittals by a Consulting Engineer or Engineering Firm shall include:
1. A copy of your written authorization to represent, signed by the legal
permit Applicant; and
2. Upon completion of proposed work, a signed copy of DWRs Engineer's
Certification form attesting that the project was completed in accord
with the DWR approved COC/ATC, as issued.
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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:
Title:
(Please review 15A NCAC 02H. 106(e)for defmition of authorized signing officials)
Click here to enter a date.
(Signature of icant) (Date Signed)
Page 5 of 7 Revised:A. Orlando NPDES 21Sept2017

Application for Certificate of Coverage (COC) and/or Authorization to Construct(ATC)
under General-Permit NCG550000
•
Page 6 of 7 Revised:A. Orlando NPDES 21Sept2017

Application for Certificate of Coverage (COC) and/or Authorization to Construct(ATC)
under General-Permit NCG550000
NOTE: Treatment System Maintenance is Required-Upon receiving a Certificate of
Coverage/Authorization to Construct(COC/ATC),the Division recommends that the Permittee solicit
manufacturer-certified training, or solicit a qualified contractor or service to regularly inspect and
maintain this treatment system. The Permittee is responsible under this COC/ATC to maintain all
components of the approved treatment system, designed to meet Surface Water Quality Standards [see
attached Operation and Maintenance Agreement].
Compliance duties include:
• paying your annual fee [due on the anniversary of COC/ATC effective date],
• following the manufacturer's guidelines,
• conducting and documenting inspections, in compliance with General Permit NCG550000,
• establishing sources for OEM spare parts and supplies,
• taking discharge samples for analysis,and logging the results,
• making necessary repairs,documenting said maintenance in logs, and
• keeping logs onsite for the life of the permit,available for DWR inspection.
North Carolina General Statute$ 143-215.6B 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 this Article or a rule implementing this
Article; or who knowingly makes a false statement of a material fact in a rulemaking proceeding or contested
case under this Article; or who falsifies, tampers with, or knowingly renders inaccurate any recording or
monitoring device or method required to be operated or maintained under this Article or rules of the Commission
implementing this Article, shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten
thousand dollars($10,000). 18 U.S.C. Section 1001 provides a punishment by a fine or imprisonment not more
than 5 years,or both,for a similar offense.
Application must be accompanied by a check or money order for$60.00
made payable to:
NCDEQ
• • • • •
Mail this application and one copy of the entire package (with check) to:
NCDEQ/DWR/NPDES
Attention: John Hennessy, Supervisor
Compliance and Expedited Permitting Unit
1617 Mail Service Center
Raleigh,North Carolina 27699-1617
Attn: John Hennessy
Note: Submission of this document insures DWR's consideration, but does not
guarantee issuance of a Certificate of Coverage/Authorization to Construct.
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