NC0070033_Regional Office Historical File Pre 2016

WDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
August 14, 2015
Rodney R Sides
Frog Level Industries Inc.
PO Box 208
Lewisville, NC 270230208
Subject: NOTICE OF VIOLATION
NOV-2015-MV-0100
Permit No. NCO070033
Quail Run Mobile Home Park
Davidson County
Dear Mr. Sides:
Donald R. van der Vaart
Secretary
A review of Quail Run Mobile Home Park's monitoring report for April 2015 showed the following violation:
Parameter
Date
Measuring
Frequency
Violation
DO, Oxygen, Dissolved
4/4/2015
Weekly
1 J
Remedial actions, if not already implemented, should be taken to correct the above noncompliance
problem. Please be aware that violations of your NPDES permit could result in enforcement action by the
Division of Water Resources for this and any additional violations of State law.
If you should have any questions, please do not hesitate to contact Jenifer Carter at [phone].
cc: DWR — Central Files
WSRO Files
Sincerely,
W. Corey Basinger, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NC DENR
450 W. Hanes Mill Rd, Suite 300; Winston-Salem, NC 27105
Phone: [phone] Internet: www.ncdenr.gov
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NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
June 19, 2015
Frog Level Industries Inc
Attn: Rodney R. Sides
P.O. Box 208
Lewisville, NC 27023-0208
Subject: NOTICE OF VIOLATION
NOV-2015-LV-0402
Permit No. NCO070033
Quail Run Mobile Home Park
Davidson County
Dear Mr. Sides:
Donald R. van der Vaart
Secretary
A review of Quail Run Mobile Home Park's monitoring report for March 2015 showed the following
violation:
Parameter
Date
Limit Value
Reported Value
Limit Type
Coliform, Fecal MF,
M-FC Broth,44.5C
3/6/2015
400.000 #/100ml
12,000.000 #/100mI
Daily Maximum Exceeded
Remedial actions, if not already implemented, should be taken to correct the above noncompliance
problem. Please be aware that violations of your NPDES permit could result in enforcement action by the
Division of Water Resources for this and any additional violations of State law.
If you should have any questions, please do not hesitate to contact Jenifer Carter at [phone].
cc: DWR — Central Files
WSRO Files
Sincerely,
i611,11
I�'W. Corey Basinger, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NC DENR
450 W. Hanes Mill Rd, Suite 300; Winston-Salem, NC 27105
Phone: [phone] Internet: www.ncdenr.gov
An Equal Opportunity 1 Affirmative Action Employer — Made in part by recycled paper

A7jf2
f
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
June 19, 2015
Frog Level Industries Inc
Attn: Rodney R Sides
PO Box 208
Lewisville, NC 270230208
Subject: NOTICE OF VIOLATION
NOV-2015-LV-0394
Permit No. NCO070033
Quail Run Mobile Home Park
Davidson County
Dear Mr. Sides:
Donald R. van der Vaart
Secretary
A review of Quail Run Mobile Home Park's monitoring report for February 2015 showed the following
violation:
Parameter
Date
Limit Value
Reported Value
Limit Type
Coliform, Fecal MF,
M-FC Broth,44.5C
2/20/2015
400.000 #/100ml
520.000 #/100ml
Daily Maximum Exceeded
Remedial actions, if not already implemented, should be taken to correct the above noncompliance
problem. Please be aware that violations of your NPDES permit could result in enforcement action by the
Division of Water Resources for this and any additional violations of State law.
If you should have any questions, please do not hesitate to contact Jenifer Carter at [phone].
cc: DWR — Central Files
WSRO Files
Sincerely,
6r W. Corey Basinger, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NC DENR
450 W. Hanes Mill Rd, Suite 300; Winston-Salem, NC 27105
Phone: [phone] Internet: www.ncdenr.gov
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NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
12/22/2014
Frog Level Industries, Inc.
Attn: Mr. Rodney R. Sides
P.O. Box 208
Lewisville, NC 27023-0208
Subject: NOTICE OF VIOLATION
NOV-2014-LV-0547
Permit No. NCO070033
Quail Run Mobile Home Park
Davidson County
Dear Mr. Sides:
John E. Skvarla, III
Secretary
A review of Quail Run Mobile Home Park's monitoring report for September 2014 showed the following
violation:
Parameter
Date
Limit Value
Reported Value
Limit Type
Coliform, Fecal
9/19/2014
400.000 #/100ml
6,400.000 #/100ml
Daily Maximum Exceeded
Remedial actions, if not already implemented, should be taken to correct the above noncompliance problem.
Please be aware that violations of your NPDES permit could result in enforcement action by the Division of
Water Resources for this and any additional violations of State law.
If you should have any questions, please do not hesitate to contact Jenifer Carter at [phone].
cc: DWR — Central Files
WSRO Files
Sincerely,
W. Corey Basinger, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NC DENR
450 W. Hanes Mill Rd, Suite 300; Winston-Salem, NC 27105
Phone: [phone] Internet: www.ncdenr.gov
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NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
Mr. Rodney R. Sides
Frog Level Industries, Inc.
P.O. Box 208
Lewisville, NC 27023-0208
SUBJECT: Compliance Evaluation Inspection
Quail Run Mobile Home Park WWTP
NPDES Permit No. NCO070033
Davidson County
Dear Mr. Sides:
September 12, 2014
John E. Skvarla, III
Secretary
On August 21, 2014, Ms. Jenifer Carter of the Winston-Salem Regional Office conducted a Compliance Evaluation
Inspection at Quail Run Mobile Home Park's Wastewater Treatment Facilities. Mr. Luther Leonard, ORC, was
present during the inspection.
Findings during the inspection:
A) Overall, the system appeared to be in good condition and operated sufficiently.
B) Records were complete and consistent, including maintenance logs.
C) Mr. Leonard alternates between the two sides of the sand filter weekly, using 3 of 5 arms on each side. He
finds this to provide sufficient treatment.
Should you have any questions please contact Jenifer Carter in our Winston-Salem Regional Office at [phone]
or .Jenifer.Carter(cr�,ncdenr.gov. Please be aware that the WSRO will be relocating soon. Emai ling WSRO staff maybe
the best way to contact them during the transition. Emergencies can continue to be reported to 1-800-858-0368.
Updated contact information for the new location will be made public as soon as it is available.
Sincerely,
"A
`'" W. Corey Basinger, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NC DENR
attachment
cc: Luther Leonard (502 Northside Dr; Lexington, NC 27295)
DWR-Central Files
WSRO Files
585 Waughtown St., Winston-Salem, NC 27107
Phone: [phone] Internet: www.ncdenr.gov
An Equal Opportunity 1 Affirmative Acton Employer — Made in part by recycled paper

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 u 2 u 3 1 NCO070033 111 12 14/08/21 17
18 ICI 19 I G j 201
21111111111111111111111111111111111111111111
I�
Inspection
Work Days Facility Self -Monitoring Evaluation Rating B1 QA
—------------- —----- Reserved --- —----- ----
67
70 71 J�ti � 72 L N J
LJ LJ
73I I I74 751 1 1 1 1 1 1 180
I I I
Section B: FacilityData
Name and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
Entry Time/Date
Permit Effective Date
POTW name and NPDES oermit,Number)
10:OOAM 14/08/21
14/07/01
Quail Run Mobile Home Park
136 Quail Place Dr
Exit Time/Date
Permit Expiration Date
Winston Salem NC 27127
10:30AM 14/08/21
19/05/31
Name(s) of Onsite Representative(s)Mtles(s)/Phone and Fax Number(s)
Other Facility Data
Luther C. Leonard//336-249-7439 /
Name, Address of Responsible OfficiaUritle/Phone and Fax Number
Carolyn A Caldwell, PO Box 935 Stanleytown VA 241681/276-340-30311 Contacted
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit 0 Flow Measurement Operations & Maintenance N Records/Reports
Self -Monitoring Program 0 Facility Site Review Effluent/Receiving Waters
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
Jen Carter . ) WSRO WQ//336-771-5000/
3
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers
Date
'� i l.['/ti+^ ;� .tea, f ��f
°--•�l � �
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page#

NPDES yr/mo/day Inspection Type
31 NCO070033 I11 12 14/08/21 17 18 , ,
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
Page#

Permit: NCO070033 Owner - Facility: Quail Run Mobile Home Park
' Inspection Date: 08/21/2014 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
❑
❑
N
❑
application?
Is the facility as described in the permit?
❑
0
❑
❑
# Are there any special conditions for the permit?
0
❑
❑
❑
Is access to the plant site restricted to the general public?
0
❑
❑
❑
Is the inspector granted access to all areas for inspection?
0
❑
❑
❑
Comment: Dechlor unit not included in facility description.
Record Keeping
Yes No NA NE
Are records kept and maintained as required by the permit?
N
❑
❑
❑
Is all required information readily available, complete and current?
0
❑
❑
❑
Are all records maintained for 3 years (lab. reg. required 5 years)?
N
❑
❑
❑
Are analytical results consistent with data reported on DMRs?
N
❑
❑
❑
Is the chain -of -custody complete?
❑
❑
❑
Dates, times and location of sampling
Name of individual performing the sampling
Results of analysis and calibration
Dates of analysis
Name of person performing analyses
Transported COCs
Are DMRs complete: do they include all permit parameters?
0
❑
❑
❑
Has the facility submitted its annual compliance report to users and DWQ?
❑
❑
❑
(If the facility is = or > 5 MGD permitted flow) Do they operate 24/7 with a certified operator
❑
❑
0
❑
on each shift?
Is the ORC visitation log available and current?
N
❑
❑
❑
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?
0
❑
❑
❑
Is a copy of the current NPDES permit available on site?
0
❑
❑
❑
Facility has copy of previous year's Annual Report on file for review?
❑
❑
❑
Comment:
Effluent Sampling Yes No NA NE
Is composite sampling flow proportional? ❑ ❑ 0 ❑
Is sample collected below all treatment units? 0 ❑ ❑ ❑
Page# 3

Permit: NCO070033 Owner - Facility: Quail Run Mobile Home Park
Inspection Date: 08/21/2014 Inspection Type: Compliance Evaluation
Effluent Sampling
Yes No NA NE
Is proper volume collected?
E❑
❑
❑
Is the tubing clean?
❑
❑
0
❑
# Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees
❑
❑
0
❑
Celsius)?
Is the facility sampling performed as required by the permit (frequency, sampling type
❑
❑
❑
representative)?
Comment:
Upstream / Downstream Sampling Yes No NA NE
Is the facility sampling performed as required by the permit (frequency, sampling type, and ❑ ❑ ❑
sampling location)?
Comment:
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? 0 ❑ ❑ ❑
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?
❑
❑
❑
Is septic tank pumped on a schedule?
0
❑
❑
❑
Are pumps or syphons operating properly?
❑
❑
❑
E
Are high and low water alarms operating properly?
❑
❑
❑
0
Comment: There are 5 septic tanks throughout the collection system serving
the mobile home Dark
Sand Filters (Low rate)
Yes No NA NE
(If pumps are used) Is an audible and visible alarm Present and operational?
❑
❑
❑
Is the distribution box level and watertight?
❑
❑
❑
Is sand filter free of ponding?
N
❑
❑
❑
Is the sand filter effluent re -circulated at a valid ratio?
0
❑
❑
❑
# 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)
0
❑
❑
❑
Comment: Mr. Leonard uses 3 of 5 arms per side of the filter, and rotates from one side to the other
weekly.
Page# 4

Permit: NC0070033 Owner - Facility: Quail Run Mobile Home Park
i
Inspection Date: 08/21/2014 Inspection Type: Compliance Evaluation
Sand Filters (Low rate) Yes No NA NE
Disinfection -Tablet
Yes No NA NE
Are tablet chlorinators operational?
N
❑
❑
❑
Are the tablets the proper size and type?
0
❑
❑
❑
Number of tubes in use?
2
Is the level of chlorine residual acceptable?
0
❑
❑
❑
Is the contact chamber free of growth, or sludge buildup?
0
❑
❑
❑
Is there chlorine residual prior to de -chlorination?
0
❑
❑
❑
Comment:
De -chlorination Yes No NA NE
Type of system ? Tablet
Is the feed ratio proportional to chlorine amount (1 to 1)? ❑ ❑ 0 ❑
Is storage appropriate for cylinders? ❑ ❑ 0 ❑
# Is de -chlorination substance stored away from chlorine containers? 0 ❑ ❑ ❑
Comment:
Are the tablets the proper size and type? E ❑ ❑ ❑
Are tablet de -chlorinators operational? 0 ❑ ❑ ❑
Number of tubes in use? 1
Comment:
Page# 5

AWIMA
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
August 22, 2014
Mr. Rodney R Sides
Frog Level Industries Inc
PO Box 208
Lewisville, NC 270230208
Subject: NOTICE OF VIOLATION
NOV-2014-LM-0026
Permit No. NCO070033
Quail Run Mobile Home Park
Davidson County
Dear Mr. Sides:
John E. Skvarla, III
Secretary
A review of Quail Run Mobile Home Park's monitoring report for May 2014 showed the following
violations:
Parameter
Date
Limit Value
Reported Value
Limit Type
Nitrogen, Ammonia Total (as N)
- Concentration
5/31/2014
6.900 mg/1
7.350 mg/1
Monthly Average Exceeded
Parameter
Week Ending
Measuring Frequency
Violation
Chlorine, Total Residual
5/3/2014
2 X week
Monitored only 1X
Remedial actions, if not already implemented, should be taken to correct the above noncompliance problem.
Please be aware that violations of your NPDES permit could result in enforcement action by the Division of
Water Resources for this and any additional violations of State law.
If you should have any questions, please do not hesitate to contact Jenifer Carter at [phone].
cc: DWR — Central Files
WSRO Files
Sincerely,
W. Corey Basinger, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NC DENR
585 Waughtown St., Winston-Salem, NC 27107
Phone: [phone] Internet: www.ncdenr.gov
An Equal Opportunity 1 Affirmative Action Employer— Made in part by recycled paper

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Facility: QLa j n M 419 Permit No.: C 093 Pipe No.: a- I MonthNear Cc
Monthly Average Violations
Parameter
Permit Limit
DMR Value
% Over Limit Action
Weekly/Daily
Violations
Date
Parameter
Permit Limit Limit Type
DMR Value
% Over Limit Action
Monitoring Frequency Violations
Date
Parameter
Permit Frequency
Values Reported
# of Violations Action
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Regional Supervisor Sign
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NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
April 4, 2014
Frog Level Industrial
Attn: Mr. Rodney Sides
P.O. BOX 208
Lewisville, NC 27023
Subject: NOTICE OF VIOLATION
NOV-2014-LV-0153
Permit No. NCO070033
Quail Run Mobile Home Park
Davidson County
Dear Mr. Sides:
John E. Skvarla, III
Secretary
A review of Quail Run Mobile Home Park's monitoring report for December 2013 showed the following
violation:
Parameter
Date
Limit Value
Reported Value
Limit Type
Coliform, Fecal
12/17/13
400 #/100ml
1,000 #/100m1
Daily Maximum Exceeded
Remedial actions, if not already implemented, should be taken to correct the above noncompliance problem.
Please be aware that violations of your NPDES permit could result in enforcement action by the Division of
Water Resources for this and any additional violations of State law.
If you should have any questions, please do not hesitate to contact Jenifer Carter at [phone].
cc: DWR — Central Files
WSRO Files
Sincerely,
W. Corey Basinger, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NC DENR
585 Waughtown St., Winston-Salem, NC 27107
Phone: [phone] Internet: www.ncdenr.gov
An Equal Opportunity 1 Affirmative Action Employer — Made in part by recycled paper

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Parameter
DMR Review Record
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Monthly Average Violations
Permit Limit DMR Value % Over Limit Action
Weeklv/Daily Violations
Date
Parameter
Permit Limit Limit Tvpe
DMR Value
% Over Limit Action
12 _
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Monitoring Frequency Violations
Date
Parameter
Permit Frequency
Values Reported
# of Violations Action
Other Violations/Staff Remarks:
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Supervisor Remarks: l
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Completed by: ` J . jP Date: Z 3` 7 o I V
Assistant Regional
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Regional Supervisor Sign Zo G
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Mickey, Mike
From: Mickey, Mike
Sent: Thursday, March 20, 2014 4:25 PM
To: '[e-mail]'
Cc: Carter, Jenifer
Subject: Quail Acres MHP - NPDES Permit No. NC0070033
Attachments: Name -Owner -Change- Form FiIlable-20130901-DWR-SWP-NPDES- l.docx
Rod — Per your request, attached is the change of ownership form. Please complete and submit to the address listed on
page 2. Let me know if you have any questions. Thanks, Mike.
Mike Mickey
Mike.Mickev(&NCDENR.eov
NC Division of Water Resources
585 Waughtown Street
Winston-Salem, NC 27107
Phone: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the North
Carolina Public Records Law and may be disclosed to third parties.
A x
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NA
1

RECEIVED
N.C.Deot. of ENR
A=4*A �M�
NCDENR
Winston-Salem
Re^;cr=' O, lce_ —
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
November 20, 2013
Attn: Fred P. Cox
Quail Run Mobile Home Park
136 Quail Place Drive
Winston-Salem, NC 27127
Subject: Receipt of permit renewal application
NPDES Permit NCO070033
Davidson County
Dear Mr. Cox,
John E. Skvarla, III
Secretary
The NPDES Unit received your permit renewal application on November 19th, 2013. This
permit renewal has been assigned to Charles Weaver (919-807-6391) who will contact you if
any additional information is required to complete your permit renewal. Due to current backlog
you should continue to operate under the terms of your current permit, until a new permit is
issued. If you have any questions, please contact the assigned permit writer.
Sincerely,
Jeff Poupart
Point Source Branch Program Supervisor IV
Cc: Central Files
Winton -Salem Office
NPDES Unit
1601 Mail Service Center, Raleigh, North Carolina 27699-1601 One
Phone: [phone] Internet: www.ncdenr.gov NorthCarohna
An Equal Opportunity, 1 Affirmative Action Employer — 50% Recycled 110% Post Consumer Paper Natumlly

QUAIL RUN MOBILE HOME PARK
136 QUAIL PLACE DRIVE
WINSTON-SALEM, NC 27127
November 13, 2013
Wren Thedford
NC DENR / NPDES Unit
1617 Mail Service Center
Raleigh, N.C. 27699-1617
Re: Renewal, NPDES Permit NCO070033
RECEIVED i
N.C.Dept. of r�NR
i
NOV 2 ; 201
Winston-Salem
Reaiona! Office
2 L9 R
D
FNV 19 2013
Please accept my request for renewal of the permit for our sewage treatment operation.
Enclosed is the application and related forms
There has been no changes made to the system since our last renewal.
Respectfully submitted,
QUAIL RUN MOBILE HOME PARK
Fred P. Cox
Owner
Enclosures

QUAIL RUN MOBILE HOME PARK
136 QUAIL PLACE DRIVE
WINSTON-SALEM, NC 27127
November 13, 2013
Wren Thedford
NC DENR / NPDES Unit
1617 Mail Service Center
Raleigh, N.C. 27699-1617
Re: Renewal, NPDES Permit NCO07003
DESCRIPTION OF SLUDGE MANAGEMENT PLAN
Septic Tanks are pumped every three months by Forsyth Rooter Service, Inc.,
P O Box 24248, Winston-Salem, NC 27114, telephone [phone]

61
NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 1000/6 domestic wastewaters <1.0 MGD
Mail the complete application to:
N. C. DENR / Division of Water Resources / NPDES Program
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit FNC001003-3
If you are completing this form in computer use the TAB key or the up - down arrows to move from one
field to the next. To check the boxes, click your mouse on top of the box. Otherwise, please print or type.
1. Contact Information:
n
Owner Name
Facility Name
Mailing Address
City e uJ rJ
State / Zip Code �l A oZ 4
Telephone Number L% 8/7- p /9 Z) D ,Q
Fax Numberj�)
e-mail Address p :54 - e�
2. Location of facility producing discharge:
Check here if same address as above ❑
Street Address or State Road /2/ �=K-u/{ �L4e& Del VV-
city (Ai /'djkYPA(-
State / Zip Code a 7 a 7
County �A} l f iltS 0_
3. Operator Information:
Name of the firm, public organization or other entity that operates the facility. (Note that this is not
referring to the Operator in Responsible Charge orrORC)
[. /
Name _ ' T_�, Px e� ?•
Mailing Address ,�Q o1 /1I0 Si��CN_ 0.0/'✓e-
city i✓9 `%
State / Zip Code �c 2 72 9.5
Telephone Number (3U a 39 • `D 84 .*�
Fax Number ( ) Aft) d Q--
e-mail Address �,C (, �, a Ktt� U , -A00 . CV M
1 of 3 Form-D 9/2013

r
NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 1000/6 domestic wastewaters <1.0 MGD
4. Description of wastewater:
Facility Generating Wastewater(check all that apply
Industrial
❑
Number of Employees
Commercial
❑
Number of Employees
Residential
0-11'
Number of Homes cam_
School
❑
Number of Students/Staff
Other
❑
Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Number of persons served:
5. Type of collection system
E3'­S�eparate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
b. Outfall Information:
Number of separate discharge points
Outfall Identification number(s) OD /
Is the outfall equipped with a diffuser? ❑ Yes W-No
?. Name of receiving stream(s) (NEW applicants: Provide a map showing the exact location of each
outfallt
S. Frequency of Discharge: Q,,Gontinuous ❑ Intermittent
If intermittent:
Days per week discharge occurs: Duration: _
9. Describe the treatment system
List all installed components, including capacities, provide design removal for BOD, TSS, nitrogen and
phosphorus. If the space provided is not sufficient, attach the description of the treatment system in a
separate sheet of paper.
2 of 3 Form-D 11 /12

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow O. o/ 7 MGD
Annual Average daily now . Do 78 MGD (for the previous 3 years)
Maximum daily now . 00 MGD (for the previous 3 years)
11. is this facility located on Indian country?
❑ Yes a No
12. Effluent Data
NSW APPLICANTS: Provide data for the parameters listed. Fecal Conform, Temperature and pH shall be grab
samples, for all other parameters 24-hour composite sampling shall be used. If more than one analysis is reported,
report daily maw um. and monthly average. If only one analysis is reported, report as daily nmunum.
RENEWAL APPLICANTS: Provide the highest single reading (Daily Maximum.) and Monthly Average over
tho nnct 3A mnnths for nnramptem currently in your permit. Mark other parameters "N/A".
- -- - - - - - Parameter
(Daily
Maximum
Monthly
Average
Units of
Measurement
Biochemical Oxygen Demand (BOD5)
15.9
L
Fecal Coliform
< /
Total Suspended Solids
49. a
Temperature (Summer)
a3
•C
Temperature (Winter)
C
pH
n/ it
i✓
/✓ .j
13. List all permits, construction approvals and/or applications:
Type Permit Number Type Permit Number
Hazardous Waste (RCRA)
UIC (SDWA)
NPDES
PSD (CAA)
NESHAPS (CAA)
Ocean Dumping (MPRSA)
Azd gp ? o 0 3.3 Dredge or fill (Section 404 or CWA)
Other
Non -attainment program (CAA)
14. APPLICANT CERTIFICATION
I certify that I am familiar with the information contained in the application and that to the
best of my knowledge and belief such information is true, complete, and accurate.
/-',eee CQ)C Dwn/P2
Printed name of Berson Signing Title
/-/5,_
Signature of AppliTcant Date
North Carolina General Statute 143-215.6 (bX2) states: Any person who knowingly makes any false statement representation, or certification in any
application, record, report, plan, or other document files or required to be maintained under Arline 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
ra pired to be operated or maintained under Article 21 or regulations of the Environmental Management Commission implementing that Article, shall be
guilty of a misdemeanor punishaNe by a fine not to exceed $25,000, or by imprisonment not to exceed sic 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.)
3 of 3 Form-D 11/12

AT_KWJ
NCDEENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
Quail Run Mobile Home Park
Attn: Fred P. Cox
136 Quail Place Dr.
Winston-Salem, NC 27127
Subject: NOTICE OF VIOLATION
Permit No. NCO070033
Quail Run Mobile Home Park
Davidson County
Dear Mr. Cox:
Division of Water Quality
Thomas A. Reeder
Acting Director
July 15, 2013
John E. Skvarla, III
Secretary
A review of Quail Run Mobile Home Park's monitoring report for April 2013 showed the following violations:
Parameter
Date
Limit Value
Reported Value
Limit Type
Nitrogen, Ammonia Total (as N)
04/30/13
6.9 mg/1
8.19 mg/l
Monthly Average Exceeded
Remedial actions, if not already implemented, should be taken to correct the above noncompliance problem.
Please be aware that violations of your NPDES permit could result in enforcement action by the Division of
Water Quality for this and any additional violations of State law.
If you should have any questions, please do not hesitate to contact Jenifer Carter at [phone].
cc: SWP — Central Files
WSRO Files
North Carolina Division of Water Quality, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem, North Carolina 27107
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748
Internet: wvvw.ncwaterquality.org
Sincerely,
W. Corey Basinger
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality
NorthCarolina
Naturally
An Equal Opportunity l Affirmative Action Employer

Cover Sheet from
�k Staff Member to
Regional Supervisor
/ `� DMR Review Record
Facility:(-G(G / /CG�/7 %�y� Permit/Pipe No.:Akol)7-00� 5 Month/Ye 22 Zd t 3
Monthly Averalce Violations
Parameter Permit Limit DMR Value % Over Limit
Date Parameter
Date
Weekly/Daily Violations
Permit Lire tff ype DMR Value % Over Limit
Monitoring Frequency Violations
Parameter Permit Frequency Values Reported # of Violations
Other Violations
/2 Oye.-
�c�1�S are ,read &�v\ t,)nh- /VtQik, 3(1 41,3 A) /5- /ykjer 7q4 � �1,q(
rr
Completed by: r-4-ev Date:
Regional Water Quality
Supervisor Signoff:
Date: 6 3

NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
Fred P. Cox
136 Quail Place Dr.
Winston-Salem, NC 27127
Subject: NOTICE OF DEFICIENCY
NOD-2013-LV-0004
Permit No. NC0070033
Quail Run Mobile Home Park
Davidson County
Dear Mr. Cox:
Division of Water Quality
Charles Wakild, P.E.
Director
January 9, 2013
John E. Skvarla, III
Secretary
A review of Quail Run Mobile Home Park's monitoring report for October 2012 showed the following
deficiency:
Parameter
Date
Limit Value
Reported Value
Limit Type
Flow
10/31/12
FO.017 mgd 1
0.0172 mgd
Monthly Average Exceeded
Remedial actions should be taken to correct the cause(s) of this deficiency. Unresolved deficiencies may lead to
the issuance of a Notice of Violation and/or assessments of civil penalties by the Division of Water Quality of
up to $25,000.00 per day for each violation. Any efforts undertaken to bring the facility back into compliance
are not an admission of culpability. Your response, the degree and extent of harm to the environment, and the
duration and gravity of the deficiency will be considered in any future actions undertaken.
If you should have any questions, please do not hesitate to contact Jenifer Carter at [phone].
Sincerely,
W. Corey Basinger
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality
cc: SWP — Central Files
WSRO Files
North Carolina Division of Water Quality, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem, North Carolina 27107
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
NorthCarohna
Naturally
An Equal Opportunity 1 Affirmative Action Employer

12
PoD
Cover Sheet from
Staff Member to
Regional Supervisor
DNIR Review Record
Facility: _ 60 4jr? n'W Permit/Pipe No.: IV C 067(5033 Month/Year o-96 /3,
Monthly Average Violations
Parameter Permit Limit DMR Value % Over Limit
Date Parameter
Date Parameter
s
DMR Value % Over Limit
Monitoring Frequency Violations
Permit Frequency Values Reported # of Violations
Weekly/Daily Violation
Permit Limit/Type
Other Violations lA 3 �— i2 ryiat/-h S
/V OP b 0l� �vri
01 12C4 ��
ic�(°I/ �ay� �, ���uvt� v �� iP ��
Completed by: _ ✓ Date: / 3 i
Regional Water Quality
Supervisor Signoff: Date:
N�/

North Carolina
Beverly Eaves Perdue
Governor
CAROLYN A CALDWELL
ASSISTANT MANAGER
QUAIL RUN MOBILE HOME PARK
PO BOX 935
STANLEYTOWN VA 24168
Dear Ms. Caldwell:
��
JG
RECEIVED
NCDENR
N.C.Dept. of ENR
Department of Environment and Natural Resour
es NOV 2 s 2012
Division of Water Quality
Winston-Salem
Chuck Wakild
I Re io
Director
Secretary
November 26, 2012
Subject: NPDES Permit Modification- Name and/or
Ownership Change
Permit Number NCO070033
Quail Run Mobile Home Park
Davidson County
Division personnel have reviewed and approved your request to transfer ownership of the subject permit, received
on November 7, 2011. This permit modification documents the change of ownership.
Please find enclosed the revised permit. All other terms and conditions contained in the original permit remain
unchanged and in full effect. This permit modification is issued under the requirements of North Carolina General
Statutes 143-215.1 and the Memorandum of Agreement between North Carolina and the U.S. Environmental Protection
Agency.
If you have any questions concerning this permit modification, please contact the Point Source Branch at (919)
807-6304.
cc: Central Files
Winston-Salem Regional Office, Surface Water Protection
NPDES Unit File NCO070033
Ib1i Mad',ervice Center, Rale,gh, ! ,.'I, Carolina 2,699-io17
i_- Aoii: J1 L f i Sallsbury Y i,alt nh, 1:owi Caroldia 2 -4
Phone: 91° P; �1001 F " 9!() J7 _ : (,ust,r-ei Sen ire: 1 5z?-6,4n
In,'- uo`: www ­-w;.,erc,ialh ,
sOppnri„nq 1 Af'iirmab:, ni .:-q Empr,yer
One
NortliCarolina
Aw11 rallif

Permit NCO070033
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
PERMIT
TO DISCHARGE WASTEWATER UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provisions 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,
Fred P. Cox
is hereby authorized to discharge wastewater from a facility located at
Quail Run Mobile Home Park
136 Quail Place Drive
Winston-Salem
Davidson County
to receiving waters designated as Miller Creek in subbasin 03-07-04 of the Yadkin -Pee Dee
River Basin in accordance with effluent limitations, monitoring requirements, and other
conditions set forth in Parts I, II, III, and IV hereof.
The permit shall become effective December 1, 2012.
This permit and the authorization to discharge shall expire at midnight on May 31, 2014.
Signed this day November 28, 2012.
Chuck Waklid, Director
Division of Water Quality
By Authority of the Environmental Management Commission

Permit NCO070033
SUPPLEMENT TO PERMIT COVER SHEET
All previous NPDES Permits issued to this facility, whether for operation or discharge are
hereby revoked, and as of this issuance, any previously issued permit bearing this number is
no longer effective. Therefore, the exclusive authority to operate and discharge from this
facility arises under the permit conditions, requirements, terms, and provisions included
herein.
Fred P. Cox is hereby authorized to:
1. Continue to operate an existing 0.017 MGD wastewater treatment plant that includes the
following components:
• Two 3,200 gallon septic tanks
• One 4,000 gallon septic tank
• Two 4,500 gallon septic tanks
• 8,400 gallon recirculating dosing tank
• 4,250 square foot recirculating surface sandfilter
• Tablet chlorinator
• 350 gallon chlorine contact tank
This permitted facility is located at the Quail Run Mobile Home Park WWTP [136 Quail
Place Drive, Winston-Salem] in Davidson County.
2. Discharge from said treatment works at the location specified on the attached map into
Miller Creek, currently classified C waters in subbasin 03-07-04 of the Yadkin -Pee Dee
River Basin.

Permit NCO070033
A. (1) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS
Beginning on the effective date of this permit and lasting until permit expiration, the Permittee is
authorized to discharge from Outfall 001. Such discharges shall be limited and monitored by the Permittee
as specified below:
PARAMETER
Flow
....................... .._...... ------- -----------.._.
BOD5
.................... ...................................................... _........ _.._..._.
Total Suspended Solids
................................ ......_... __....... _..................................
NH3-N
(April 1 - October 31)
..........................................._............................_..._.........__.......
NH3-N
(November 1- March 31)
..................... _......
---._...__.........._._.._....
Dissolved Oxygen
(April 1- October 31)
................. ..................... .._........ ---............ -............ --....
Fecal Coliform
(Geometric Mean)
..........................................................._........_........_....._...........
Total Residual Chlorine2
Temperature
................... ...._... ...- - --- ...__...... ---
Total Nitrogen
(TKN + NO2 + NO3)
............................._....._._........__..._-... ............... -......
Total Phosphorus
........................................ ---..... ............ ....................
pH
EFFLUENT LIMITATIONS
Monthly Average
Daily Maximum
0.017 MGD
.............................. ..........-.-............ _..... -._... _......
30.0 mg/L
................. _.......................................................... ---.
........... _..._... _.................... -- ....................... _
45.0 mg/L
............ _... ............................................... _..........
30.0 mg/L
45.0 mg/L
6.9 mg/L
34.5 mg/L
MONITORING REQUIREMENTS
asurement
Sample Type
Sample
re uenc
Location
Influent or
Weekly
Instantaneous
Effluent
—
----- _... __
2/month
................................ -......................... ......_....-
Grab
-....._...--
Effluent
................_...........................
2/month
........................
Grab
--.._....__... - -
Effluent
2/month I Grab I Effluent
25.8 mg/L
35.0 mg/L
2/month
Grab
Effluent
..................... .... - ......... -.
---._--.._.—._.................. _.................. _..........
.._._.... __._...._......._...---_._
.._.......... _............ ...........
Effluent,
Weekly
Grab
U & D
200/100 ml
400/100 ml
2/month
Grab
Effluent
.................... ...... _....................... _.............
............ ............_................ ......--.......
..................................... .....--.........................................
28 pg/L
.......... ---.... .......................... ..................................
....................... ....-.--_................................
2/Week
........... _.._...... _
.......................................................... ....._
Grab
_--- ................... - .... - .... -...
._.__............__..-
Effluent
Effluent,
Weekly
Grab
U&D
Quarterly
Grab
Effluent
......................... __._..........- A.
..--
. ....... ......... ..-......_................ ....... ...... ..... -- -
-- .......... --_._y_....
Quarter)
--- - — -._......__...............................
.....
Grab
------ -- ........ .
-
Effluent
--- -
> 6.0 and < 9.0
Standard Units
2/month
Grab
Effluent
Notes:
1 U: upstream approximately 100 feet from the outfall. D: downstream at least 300 feet from the outfall.
2 The Permittee shall report all effluent TRC values reported by a NC -certified laboratory [including field -
certified]. Effluent values below 50 µg/L will be treated as zero for compliance purposes.
THERE SHALL BE NO DISCHARGE OF FLOATING SOLIDS OR VISIBLE FOAM IN OTHER THAN TRACE
AMOUNTS.

NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Eleanor A. Zavala, Owner
P.O. Box 631
Stanleytown, VA 24168
Subject: NOTICE OF DEFICIENCY
NOD-2012-LV-0122
Permit No. NCO070033
Quail Run Mobile Home Park
Davidson County
Dear Mrs. Zavala, Owner:
Division of Water Quality
Charles Wakild, P.E.
Director
November 19, 2012
Dee Freeman
Secretary
A review of Quail Run Mobile Home Park's monitoring report for August 2012 showed the following
deficiencies:
Parameter
Date
Limit Value
Reported Value
Limit Type
Flow
08/31/12
0.017 mgd
0.0171 mgd
Monthly Average Exceeded
Remedial actions should be taken to correct the cause(s) of these deficiencies. Unresolved deficiencies may
lead to the issuance of a Notice of Violation and/or assessments of civil penalties by the Division of Water
Quality of up to $25,000.00 per day for each violation. Any efforts undertaken to bring the facility back into
compliance are not an admission of culpability. Your response, the degree and extent of harm to the
environment, and the duration and gravity of the deficiency(ies) will be considered in any future actions
undertaken.
If you should have any questions, please do not hesitate to contact Jenifer Carter at [phone].
Sincerely,
W. Corey Basinger
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality
cc: SWP — Central Files
WSRO Files
Mr. Fred Cox (136 Quail Place Dr.; Winston-Salem, NC 27127)
Mr. Luther Leonard (502 Northside Dr.; Lexington, NC 27295)
North Carolina Division of Water Quality, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem. North Carolina 27107
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
ne
NorthCarolina
Naturally
An Equal Opportunity 1 Affirmative Action Employer

LV—Cover Sheet from
Staff Member to
Regional Supervisor
DMR Review Record
/fl op
Facility: C� l �U Permit/Pipe No.: Ivy-i0?0053 Month/Year
Monthly Average Violations
Parameter Permit Limit DMR Value % Over Limit
(�/)
d w _ 011 d76pp &D 0, A d
Date
Date
Weekly/Daily Violations
Parameter Permit Limitrrype DMR Value % Over Limit
Monitoring Frequency Violations
Parameter Permit Frequency Values Reported # of Violations
Other Violations fit S f /�2 Me"'(f hs
Completed by: �I . (-�ev Date:
Regional Water Quality'
Supervisor Signoff: Date:
jr

LPKWA
NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Eleanor A Zavala, Owner
Quail Run Mobile Home Park
1142 Dalea Bluff
Round Rock, TX 78665
Subject: NOTICE OF VIOLATION
NOV-2012-MV-0060
Permit No. NCO070033
Quail Run Mobile Home Park
Davidson County
Dear Mrs. Zavala:
Division of Water Quality
Charles Wakild, P.E.
Director
July 18, 2012
Dee Freeman
Secretary
A review of Quail Run Mobile Home Park's monitoring report for March 2012 showed the following violations:
Parameter
Quarter Ending
Required Frequency
Violation
Phosphorus, Total (as P) - Concentration
03/31/12
Quarterly
no monitoring data submitted
Nitrogen, Total (as N) - Concentration
03/31/12
Quarterly
no monitoring data submitted
Remedial actions, if not already implemented, should be taken to correct the above noncompliance problem.
Please be aware that these violations of your NPDES permit, and any additional violation of State law, could
result in enforcement action by the Division of Water Quality.
If you should have any questions, please do not hesitate to contact Jenifer Carter at [phone].
cc: SWP — Central Files
WSRO Files
North Carolina Division of Water Quality, Winston-Salem Regional Office
Location: 585 Waughtown St, Winston-Salem, North Carolina 27107
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
Sincerely,
W. Corey Basinger
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality
None
rthCarolina
;aturally
An Equal Opportunity Affirmative Action Employer

NDv 0 0 — /PY 006v Cover Sheet from
Staff Member to
Regional Supervisor
DMR Review Record
Facility: AJ('a)-AX03 Permit/Pipe No L�1atY jeua Month/Year E o70fa
rk--� rh1-lP
Monthly Average Violations
Parameter Pen -nit Limit DMR Value % Over Limit
Weekly/Daily Violations
Date Parameter Permit Limjvpe DMR Value % Over Limit
Monitoring Frequency Violations
Date Parameter Permit Frequency Values Reported # of Violations
Other Violations / S f
T) A /All . 4i-,' ) ,-J/11 r A,17 t i2 ), �f1✓,�
June �a A
0
Completed by:
(AGE Date: 7/7
Regional Water Quality
Supervisor Signoff: Date:
PA�

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Charles Wakild, P.E. Dee Freeman
Governor
Director Secretary
July 23, 2012
Ms. Eleanor A. Zavala
Quail Run Mobile Home Park
1142 Dalea Bluff
Round Rock, TX 78665
SUBJECT: Compliance Evaluation Inspection
Quail Run Mobile Home Park WWTP
NPDES Permit No. NCO070033
Davidson County
Dear Ms. Zavala:
On June 29, 2012, Ms. Jenifer Carter of the Winston-Salem Regional Office conducted a Compliance Evaluation
Inspection at Quail Run Mobile Home Park's Wastewater Treatment Facilities. Mr. Luther Leonard, ORC, was
present during the inspection.
Findings during the inspection:
A) Overall, the system appeared to be in good condition and operating sufficiently.
B) Mr. Leonard expressed concern about the previous owner/current tenant asking someone to turn sand
over on the filter bed with a shovel without his knowledge. Mr. Leonard properly stepped in and asked
that this not happen again. He has been trained not only to ensure proper performance of the system, but to
take proper safety precautions when working with the system. Any concerns about how the system is
being maintained should be discussed with Mr. Leonard himself, or with our office.
C) The audible alarm on the effluent pump station was not working, though the float pump was functioning
properly. Please work with Mr. Leonard to get the audible alarm fixed, if he hasn't already done so.
D) Chlorine and dechlorination chemicals were being stored together. For safety reasons, they must be stored
separately.
Should you have any questions please contact Jenifer Carter in our Winston-Salem Regional Office at (336) 771-
4957.
Sincerely,
W. Corey Basinger
Surface Water Regional Supervisor
Division of Water Quality
Winston-Salem Regional Office
attachment
cc: Luther Leonard (502 Northside Dr; Lexington, NC 27295)
SNAP -Central Files
WSRO Files
North Carolina Division of Water Quality, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem, North Carolina 27107
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
NorthCarolina
Naturally
An Equal Opportunity l Affirmative Action Employer

United States Environmental Protection Agency
Form Approved.
EPA Washington, D.C. 20460
OMB No. 2040-0057
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 INI 2 1 51 31 NCO070033 111 121 12/06/29 117
181 C I 191 S I 201 1
Remarks
21111111111111 111111111111111111111111111111111116
Inspection Work Days Facility Self -Monitoring Evaluation Rating 131 QA
---------- --- ----------- Reserved —--------- --- ----
671 169 70131 711 N 1 721 N I
73 L_U 74 751 1 1 1 1 1 I 180
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)
Quail Run Mobile Home Park
09:00 AM 12/06/29
09/06/01
Exit Time/Date
Permit Expiration Date
136 Quail Place Dr
Winston Salem NC 27127
09:40 AM 12/06/29
14/05/31
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
Other Facility Data
///
Luther C. LeonardH336-249-7439 /
Name, Address of Responsible Official/Title/Phone and Fax Number
Contacted
Carolyn A Caldwell,PO Box 935 Stanleytown VA 24168//276-340-3031/ Contato
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit Operations & Maintenance 0 Records/Reports
Self -Monitoring Program
Facility Site Review ■ Effluent/Receiving Waters
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
Jenifer Carter WSRO WQ//336-771-5000/
%...
7/12
Sign a of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Dat
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page # 1

NPDES yr/mo/day Inspection Type
3 NCO070033 I11 12I 12/06/29 17 181 cl
(cont.)
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
Mr. Leonard became the ORC of this facility in early 2012.
Audio alarm at effluent pump station needs servicing.
Mr. Leonard expressed concern about previous owner/current tenant asking someone to turn over sand on
the filter bed with a shovel without consulting the him first. This may have been due, in part, to frustrations
with the previous ORC's failure to properly maintain the system.
Mr. Leonard properly stepped in and asked that this not happen again. Mr. Leonard needs to be trusted to
maintain the system as he was trained to do. He has been trained not only to ensure proper performance of
the system, but to take proper safety precautions. Any concerns about how the system is being maintained
should be discussed with Mr. Leonard himself, or with the State inspector, Ms. Jenifer Carter
(336-771-4957).
Overall, the system appeared to be functioning properly.
Page # 2

r
Permit: NCO070033 Owner - Facility: Quail Run Mobile Home Park
Inspection Date: 06/29/2012 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 application?
n
■
o
o
Is the facility as described in the permit?
0011
n
# Are there any special conditions for the permit?
n
■
n
n
Is access to the plant site restricted to the general public?
■
❑
n
n
Is the inspector granted access to all areas for inspection?
■
n
n
n
Comment: Permit does not include effluent pump station.
Record Keeping
Yes
No
NA
NE
Are records kept and maintained as required by the permit?
■
n
n
Is all required information readily available, complete and current?
■
00
n
Are all records maintained for 3 years (lab. reg. required 5 years)?
■
110
n
Are analytical results consistent with data reported on DMRs?
■
n
n
n
Is the chain -of -custody complete?
■
n
n
n
Dates, times and location of sampling
■
Name of individual performing the sampling
■
Results of analysis and calibration
■
Dates of analysis
■
Name of person performing analyses
■
Transported COCs
■
Are DMRs complete: do they include all permit parameters?
■
n
n
n
Has the facility submitted its annual compliance report to users and DWQ?
❑
n
n
■
(If the facility is = or > 5 MGD permitted flow) Do they operate 24/7 with a certified operator on each shift?
■
n
n
n
Is the ORC visitation log available and current?
■
n
n
n
Is the ORC certified at grade equal to or higher than the facility classification?
■
n
n
n
Is the backup operator certified at one grade less or greater than the facility classification?
■
n
n
n
Is a copy of the current NPDES permit available on site?
■
n
n
n
Facility has copy of previous year's Annual Report on file for review?
n
n
0
■
Comment:
Effluent Sampling
Yes
No
NA
NE
Is composite sampling flow proportional?
n
n
■
Page # 3

Permit: NCO070033 Owner - Facility: Quail Run Mobile Home Park
Inspection Date: 06/29/2012 Inspection Type: Compliance Evaluation
Effluent Sampling
Yes
No
NA
NE
Is sample collected below all treatment units?
■
❑
❑
❑
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:
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? ■ ❑ ❑ ❑
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable Solids, pH, DO, Sludge ❑ ❑ ■ ❑
Judge, and other that are applicable?
Comment:
Septic Tank
(If pumps are used) Is an audible and visual alarm operational?
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)
(If pumps are used) Is an audible and visible alarm Present and operational?
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?
# Is the sand filter effluent re -circulated at a valid ratio? (Approximately 3 to 1)
Comment: see comments in summary section.
Disinfection -Tablet
Are tablet chlorinators operational?
Are the tablets the proper size and type?
Number of tubes in use?
Is the level of chlorine residual acceptable?
Yes No NA NE
Yes No NA NE
Yes No NA NE

1
Permit: NC0070033 Owner - Facility: Quail Run Mobile Home Park
Inspection Date: 06/29/2012 Inspection Type: Compliance Evaluation
Disinfection -Tablet
Is the contact chamber free of growth, or sludge buildup?
Is there chlorine residual prior to de -chlorination?
Comment:
De -chlorination
Type of system ?
Is the feed ratio proportional to chlorine amount (1 to 1)?
Is storage appropriate for cylinders?
# Is de -chlorination substance stored away from chlorine containers?
Are the tablets the proper size and type?
Comment: Need to separate chlorine/dechlor chemicals for safety reasons.
Are tablet de -chlorinators operational?
Number of tubes in use?
Comment:
Yes No NA NE
■000
■ ❑ 0 0
Yes No NA NE
Tablet
Page # 5

NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Quail Run Mobile Home Park
Ms. Eleanor A. Zavala, Owner
1142 Dalea Bluff
Round Rock, TX 78665
Subject: NOTICE OF DEFICIENCY
NOD-2012-MV-0033
Permit No. NCO070033
Quail Run Mobile Home Park
Davidson County
Dear Ms. Zavala:
Division of Water Quality
Charles Wakild, P.E.
Director
June 26, 2012
Dee Freeman
Secretary
A review of Quail Run Mobile Horne Park's monitoring report for February 2012 showed the following
violations:
Parameter
Week Ending
Required
Frequency
# of Values Reported
Flow, in conduit or thru treatment plant
02/18/12
Weekly
0
Thank you for your attention to this matter. Remedial actions should be taken to correct the cause(s) of this
violation. Unresolved violations may lead to the issuance of a Notice of Violation and/or assessments of civil
penalties by the Division of Water Quality.
If you should have any questions, please do not hesitate to contact Jenifer Carter at [phone].
cc: SAT — Central Files
WSRO Files
North Carolina Division of Water Quality, Winston-Salem Regional Office
Location: 585 Waughtown St, Winston-Salem: North Carolina 27107
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
An Equal Opportunity 1 Affirmative Action Employer
Sincerely,
W. Corey Basinger
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality
onrt NhCarohna
��itl�ralll� j

Cover Sheet from
Staff Member to
Regional Supervisor
DMR Review Record
Facility: _;�Lf�1- Pe
Monthly
Parameter Permit Limit DMR Value % Over Limit
Weekly/Daily Violations
Date Parameter Permit Limit/Type DMR Value % Over Limit
Monitoring Frequency Violations
Date Parameter Permit Fre uencv Values Reported # of Violations
.271 Y (0 1
Other Violations �c0 /2 rvcaO-s
Completed by: Date:
Regional Water Quality c I�—
Supervisor Signoff: _ Date: �Z J
/" D

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: 4yPA/✓o,f- 1 zl C11+41
Mailing Address: • &zy� 6 3%
City: State: Zip: �� Phone #: (d-34
Email address: rA lveZ' s
Signature: Date:
.........................................................y..........................................................................................
Facility Name: l'1 t I{ 11 I la I" Permit #: J L ii o" a)� 3
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM!
Facility Type & Grade:
Grade Grade
Biological WWTP Surface Irrigation N/A
Physical/Chemical Land Application N/A
Collection System
Operator in Responsible Ch
Print Full Name:
Certificate Type /
Signature:
Work Phone#:
Date: 3 — 7— l2-
"I certify at gree to my designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the rules and
regulat' ns ertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary Actions
by the ater Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
j
Print Full Name: Tn tll C. ,� e , _'_' fz( '
` Certificate Type / Grade / N ber: w9 i' Work Phone #: q' 1 q 7 /
Signature: Date: Z~ / Z
"I certify that I agree to my designation as a Back-up Op ator in Responsible Charge for the facility noted. I understand and will abide by the rules
and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
Mail or Fax to: WPCSOCC
1618 Mail Service Center
Raleigh, NC 27699-1618
Fax: [phone]
(See next page for designation of additional back-up operators. Designation of more than one back-up operator is optional.)
Revised 1-2010

Additional Back-up ORC designations
Facility Name:
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
S ignature:
Permit #:
Work Phone #:
Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the rules
and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
Bach -Up Qperator in Responsible Charge (HU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone #:
Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the rules
and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
...............................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone #:
Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the rules
and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone #:
Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the rules
and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
Revised 1-2010

6j5 e a
I
11e
WASTEWATER SYSTEM
PERFORMANCE kNNUAL REPORT
2011
RECEIVED
N.C,Dept. of ENR
General Information MAR, 2 12012
Facility Name: Quail Run MHP Winston-Salem
Regional Office
Responsible Entity: Quail Run Mobile Home Park WWTP
Contact Person: Clifford Cain
Applicable Permit (s): NPDES Permit No. NCO070033
Description of collection system or process:
Continue to operate tan existing 0.017 MGD wastewater treatment plant that includes the
following components; two 3,200 gallon septic tanks, one 4,000 gallon septic tank, two 4,500
gallon septic tanks, 8,400 gallon recirculating dosing tank, 4,250 square foot recirculating surface
sandfilter, tablet chlorinator and 350 gallon chlorine contact tank. This facility is located at the
Quail Run MHP WWTP in Davidson County. Discharge into Miller Creek, currently classified C
waters in subbasin 03-0 7-04 of the Yadkin -Pee Dee River Basin.
Summary of system performance for calendar year 2011
January 2011 RAL not ORC at this time
February 2011 RAL not ORC at this time
March 2011
RAIL not ORC at this time
April 2011
RAL not ORC at this time
May 2011
RAIL not ORC at this time
June 2011
RAL not ORC at this time
July 2011
RAL not ORC at this time
August 2011
RAL not ORC at this time
September 2011
Compliant with effluent limits
0
October 2011
Compliant with effluent limits
MAR 15 '�'�L
November 2011
Compliant with effluent limits
k �
5El4R UJAaEf�p LITY
POIN r SOURCE af;AN -.
December 2011
Compliant with effluent limits
-��

l
III° Notification
Annual notice is posted in rest home.
IV. Certification
I certify under penalty of law that this report is complete and accurate to the best of my
knowledge.
Clifford Cain
Responsible Person
Field Services Manager
Title
Research & Analytical Laboratories, Inc.
Entity
January 24, 2012
Date

f RESEARCI-I gt ANA[yTICAL •�'�Q��`& YZ ''0
0.
♦,.Q�` '•40
c(7
C
• 1. �P
LAhORATORIES, INC. _ r w : ��`� '�.,
RECEivED ¢ : ` O • C'n 15.
N.C.Dept. of ENR tN NC Z;
Analytical/Process Consultations NOV 16 2011
Winston-Salem +'•��•••O`R���• ��`�,
n CIO()
/)� a5l
Re Tonal Offlcs ��''+��iIED AtAP�, �`''•
Quail Run Date Sample Collected 10/26/11
P.O. Box 631 Date Sample Received 10/26/11
Stanleytown, VA 24168 Date Sample Analyzed 10/26/11
Attn: Fred Cox Date of Report 11/02/11
Analyses Performed by AR -YJ -KL -SA
Lab Sample Number
--------------------
7164"8
Parameter Storet # Results
BOD-5 (00310) 2.45 mg/l
TSS (00530) 2.67 mg/l
NH-3-N (00610) 1.99 mg/l
Fec Coli-MF (31616) <1 col/100 ml
NOV 0 9 2011
CENTRAL
Ec
DWQ/BOQ
Clients Sample Source EFFLUENT
Number
Time Collected (Hrs) 0837
P.O. Box 473 • 106 Short Street • Kernersville, North Carolina 27284 • 336-996-2B41 • Fax [phone]
www.randalabs.com

RESEARCh & ANA1yTiCA1
LABORATORIES, INC.
Analytical / Process Consultations
Phone [phone]
CHAIN OF CUSTODY RECORD
COMPANY
B NO. n
_
=
o
d
Z
tlYA I CK / YYAJ I C WA I CKy4misc.
y
w� y�P y� O`er
O Q� 2Ov
�J.a `
0 Q
" °� �`� �� 2 O Q ¢ Q �+�
`� ti -v �`� �� � �� �� REQUESTED ANALYSIS
STREET ADDRESS
�(
l0 ll(l1 C
PROJECT
CITY, STATE, ZIP < f
leM /1/% �
SAMPLER NAME (PLEAS P INT)
CONTACT PHONE 7t A
F,ee�Q 336 -'/7-o/ 9 �
SAMPLER SIGNATURE
SAMPLE NUMBER
(LAB USE ONLY)
D TE
TIME
COMP
GRAB
TEMP
°C
RES
CI
CHLORINE REMOVED
REMOVED
Mnrwz
fs awl
SAMPLE LOCATION I I.D.
6937
��T
I
RELINQUISHED WY
—.M�L RELINQUISHED BY
*
DA RIME
RECEIVED BY
REMARKS:
r
SAMPLE TEMPERATURE AT RECEIPT °C�-
DATEITIME
RECEIVED BY

WAWA
NCDENR
Borth Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Quail Run Mobile Home Park
Eleanor A. Zavala, Owner
1142 Dalea Bluff
Round Rock, TX 78665
Subject: NOTICE OF VIOLATION
NOV-2011-MV-0179
Permit No. NCO070033
Quail Run Mobile Home Park
Davidson County
Dear Ms. Zavala:
Division of Water Quality
Coleen H. Sullins
Director
November 7, 2011
Dee Freeman
Secretary
A review of Quail Run Mobile Home Park's monitoring report for June 2011 showed the following violations:
Parameter
Date
Frequency Required
Violation
Chlorine, Total Residual
06/11/11
2 X week
Frequency Not Met
Remedial actions, if not already implemented, should be taken to correct the above noncompliance problem.
Please be aware that these violations of your NPDES permit, and any additional violation of State law, could
result in enforcement action by the Division of Water Quality.
If you should have any questions, please do not hesitate to contact Jenifer Carter at [phone].
Sincerely,
JeN
W. Corey Basinger
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality
cc: SWP - Central Files
WSRO Files
North Carolina Division of Water Quality, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem, North Carolina 27107
Phone: [phone] FAX: [phone] Customer Service; 1-877-623-6748
Internet: www,ncwaterquality.org
Nne
orthCarolina
naturally
An Equal Opportunity Affirmative Action Employer

Cover Sheet from
Staff Member to
Regional Supervisor
DMR ReN iew Record
Facility &' I I P Permit/Pipe No.: /y0060,?J� Month/Year
Monthly Averaue Violations
Parameter Permit Limit DNIR Value °lo Over Limit
Weekly/Daily Violations
Date Parameter Permit Limit/7vpe DMR Value Over Limit
Monitorin'- Frequency Violations
Date Parameter Permit Fre uencv Values Reported # of Violations
(/'- Ty
Other Violations
Completed by: \1 `�1�-�� Date:
Regional Water Quality
Supervisor Signoff: Dater

F
A74LA.
NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Eleanor A. Zavala, Owner
1142 Dalea Bluff
Round Rock, TX 78665
Subject: NOTICE OF VIOLATION
NOV-2011-MV-0137
Permit No. NCO070033
Quail Run Mobile Home Park
Davidson County
Dear Ms. Zavala:
Division of Water Quality
Coleen H. Sullins
Director
July 19, 2011
Dee Freeman
Secretary
A review of Quail Run Mobile Home Park's monitoring report for April 2011 showed the following violations:
Parameter
Week Ending
Measuring Frequency
Violation
DO, Oxygen, Dissolved
04/02/11
Weekly
Frequency Not Met
Remedial actions, if not already implemented, should be taken to correct the above noncompliance problem.
Please be aware that these violations of your NPDES permit, and any additional violation of State law, could
result in enforcement action by the Division of Water Quality.
If you should have any questions, please do not hesitate to contact Jenifer Carter at [phone].
cc: SWP — Central Files
WSRO Files
North Carolina Division of Water Quality, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem, North Carolina 27107
Phone: [phone] FAX: [phone] Customer Service: 1-877.623-6748
Internet: www.ncwaterquality.org
Sincerely,
W. Corey Basinger
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality
NorthCarolina
,Vatumlly
An Equal Opportunity 1 Affirmative Actioo Empioyer

Cover Sheet from
Staff Member to
Regional Supervisor
DMR Review Record
33 Month1Year
Facility ' i PCf n f PermitlPipe No.: / L�7C(�
Monthly Average Violations
Parameter Permit Limit DMR Value % Over Limit
Weekly/Daily Violations
Date Parameter DMR Value % Over Limit
Monitoring Frequency Violations
Date Parameter Permit Frequencv Values Reported # of Violations
Completed by: �� �Date:
Regional Water Quality Date:
Supervisor Signoff: Ago"--

'A�
NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
CAROLYN A CALDWELL
ASSISTANT MANAGER
QUAIL RUN MOBILE HOME PARK
PO BOX 935
STANLEYTOWN VA 24168
Dear Ms. Caldwell:
Division of Water Quality
Coleen H. Sullins
Director
April 11, 2011
- Dee Freeman
RECEIVE ecretary
� °t of ENR
APR �
5 2011
j �nstcn•Salem
Re=ion. pr{ce
Subject: NPDES Permit Modification -Name and/or
Ownership Change
Permit Number NCO070033
Quail Run Mobile Home Park
Davidson County
Division personnel have reviewed and approved your request to transfer ownership of the subject permit, received
on April 1, 2011: This permit modification documents the change of ownership.
Please find enclosed the revised permit. All other terms and conditions contained in the original permit remain
unchanged and in full effect. This permit modification is issued under the requirements of North Carolina General
Statutes 143-215.1 and the Memorandum of Agreement between North Carolina and the U.S. Environmental Protection
Agency.
If you have any questions concerning this permit modification, please contact the Point Source Branch at (919)
807-6304.
Sincerely,
Coleen H. Sullins
cc: Central Files
Winston-Salem Regional Office, Surface Water Protection
NPDES Unit File NCO070033
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604 One
Phone: [phone] FAX: [phone] Customer Service:1-877.623-6748 NO hCarolina
Internet: ww�w.ncwaterquality.org Natimially
An Equal Opportunity 1 Affirmative Action Employer

Beverly Eaves Perdue, Governor
Dee Freeman, Secretary
North Carolina Department of Environment and Natural Resources
I. Please enter the permit number for which the change is requested.
NPDES Permit
IN 0 o 10 00 I=
Coleen H. Sullins, Director
Division of Water Quality
(or) Certificate of Coverage
N ig 5
11. Permit status arior to status change. %J
a. Permit issued to (company name): u i ( "RU N i9kle AvIne ,4,e
b. Person legally responsible for permit:
First MI Last
Title
p o l6e � 6-? /
Permit Holder Mailing Address
city/ State Zip
C334 ) le/7-0HO
Phone Fax
c. Facility name (discharge):ji,41/u/1 thp ,r ,gme,e,V
d. Facility address: de,lel'✓e,
Address
(.d1ZiysAN - :Sa I PM N-e . a7427
City State Zip
e. Facility contact person: 1�eed efeX
First / MI / Last Phone
III. Please provide the following for the requested change (revised permit).
a. Request for change is a result of E�'Ch ange in ownership of the facility
❑ Name change of the facility or owner
If other please explain:
b. Permit issued to (company name): l(Ju,4 i / /emu �✓ i2D &� &
c. Person legally responsible for permit: _ l e A n/O /e A • 214
First MI
d. Facility name (discharge):
e. Facility address:
f. Facility contact person:
Revised 112009
Title
Permit H lder Mailing Address
4,J,✓�O( ae-kl 2'e X4s 7 "6 55
City /State Zip
cs/a )�y�-yoi.� e1A,✓o>r.2/!✓A�A %1osPiR�
Phone E-mail Address
u�J p me &ee
'116
Address
O,LN- 0111- S.4 /Pm Al • o? %/a%
City hate Zip
Akd Al A • .4/a IVIO//
first MI Last
07L) 30-303/ Nldwe/% eAieo1y1V
Phone E-mail Address L- MC,I S� , Ne f

PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Permit contact information (if different from the person legally responsible for the permit)
Permit contact: C r 1e6lV tl ZI •
first MI Last
-A SS.i. o 1L, we -
Title
Mailing Addres
City State Zip
OZ% )J* -3031 0A jdc)e/l_e,g�o%✓G /
Phone E-mail Address �mC7 ,NG f
V. Will the permitted facility continue to conduct the same industrial activities conducted prior
to thi wnership or name change?
[Yes
❑ No (please explain)
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑/This completed application is required for both name change and/or ownership change
requests.
Legal documentation of the transfer of ownership (such as relevant pages of a contract deed,
or a bill of sale) is required for an ownership change request. Articles of incorporation are
not sufficient for an ownership change.
.......................................................................................................................
The certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE ER IFICATION (Permit holder prior to ownership change):
I, _F,2PW P . ( 0 X , 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
lic ere ed as inco plete.
Signature Date
APPLICANT CERTIFICATION
I, C-­ Leyyo2 4 - ZA a!Ittest 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.
4�f� z;- 3 - 3 0 -//
Si ature Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Revised 1/2009

FILED
DAVIDSON COUNTY, NC
DAVID T. RICKARD
REGISTER OF DEEDS
February 09. 2010 02:03:46 PIVI
DEED BOOK 1960
PAGE 774 - 777
INSTRUMENT # 2010000002644
DOCTYPE: DEED
RECORDING:$21.00
VERIFICATION:$2.00 EXCISE TAX:
$10.00
CR Fee:S6.00
Deputy: NSTANLEY
Excise Tax $ /P . 17 0 Parcel # 0300300000035
Drawn by: Norman L. Nifong
NORTH CAROLINA GENERAL WARRANTY DEED
THIS DEED made this the 261h day of January, 2010, by and between
GRANTOR
GRANTEE
FREDERIC POOLE COX, JR. and wife,
ELEANOR A. ZAVALA, married
MICHELE ANN TROXEL COX
Grantor's address:
Grantee's address:
P. O.'H.ox 631
1142 Dalea Bluff
Stanleytown, VA 24168
Round Rock, Texas 78665
The designation Grantor and Grantee as used herein shall include said parties, their heirs, successors, and
assigns, and shall include singular, plural, masculine, feminine or neuter as required by context.
WITNESSETH, that the Grantors, for a valuable consideration paid by the Grantee, the receipt
of which is hereby acknowledged, have and by these presents do grant, bargain, sell and convey unto the
Grantee, her heirs, successors and assigns, in fee simple, all that certain lot or parcel of land situated in
Davidson County, North Carolina and more particularly described as follows:
For description see EXHIBIT "A" attached hereto and incorporated herein by reference as
if frilly set forth in its entirety.
All or a portion of the property herein conveyed does not include the primary residence of Grantor.

TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and
appurtenances thereto belonging to the Grantee, her heirs, successors and assigns. in fee simple.
And the Grantors covenant with the Grantee, that Grantors are seized of the premises in fee simple,
have the right to convey the same in fee simple, that title is marketable and free and clear of all
encumbrances, and that Grantors will warrant and defend the title against the lawful claims of all persons
whomsoever.
IN TESTIMONY WHEREOF, the Grantors have hereunto set their hands and adopted the printed
word [SEAL] as their own seal.
�(� ►�� [SEAL] c`u (� "'' [SEAL]
FREDERIC POOLE COX, JR. FREDERIC POOLE COX, IR.
Attorney -in -Fact for Michele Ann Troxel Cox
STATE OF NORTH CAROLINA - COUNTY OF Forsyth
I certify that the following person(s) personally appeared before me this day, each acknowledging to me
that he or she voluntarily signed the foregoing document for the purpose stated herein and in the capacity
indicated:
Date: 1/2'
(Official SeaR,,`011.1I11ill
� s
�0 Iriy
PU ie,- _
yr ,t'ti �U \�
11lii4t`,
Jane A. Cox
Notary's printed or typed name
My commission expires: 6/22/2010

STATE OF NORTH CAROLINA — COUNTY OF Forsyth
I, Jane A. Cox ; a Notary Public of said county and state, do hereby certify that Frederic Poole Cox,
Jr., attorney -in -fact for Michele Ann Troxel Cox, personally appeared before me this day, and being by me
duly sworn, says that he executed the foregoing and annexed instrument for and in behalf Michele Ann Troxel
Cox, and that his authority to execute and acknowledge said instrument is contained in an instrument duly
executed, acknowledged and recorded in the Office of the Register of Deeds of Davidson County, North
Carolina in Book Z F6, a , Page 7 6 g , and that this instrument was executed under and by virtue
of the authority given by said instrument granting him power of attorney; that the said Frederic Poole Cox, Jr.
acknowledged to me that he voluntarily signed the foregoing document for the purpose stated therein and in
the capacity indicated for and in behalf of Michele Ann Troxel Cox.
I do further certify that I am not a party to Fhehed instrument/Date: 1/27/2010�t
Off ci Signature of Notary,
(Offic\p�)E A C0 ✓// Jane A. Cox
Notary's printed or typed name
No
P U D l j C = My commission expires: 6/22/2010
��lfl -?)

EXHIBIT "A"
BEGINNING at an iron stake in the west right-of-way of Hay Road, said iron stake
being at the southwest corner of the James W. Whetstone, Jr. property; and said
BEGINNING stake also being South 2 degrees 30 minutes West 395 feet from the
intersection of the west line of Hay Road and the south line of Hickory Tree Road;
running thence with the south line of Whetstone's property South 87 degrees 45 minutes
East 304.79 feet to an iron, the southeastern corner of the Whetstone property; thence
with Whetstone's line North 3 degrees 05 minutes 16 seconds East 94.85 feet to an iron,
Whetstone's northeastern corner; thence South 87 degrees 45 minutes East 402.95 feet to
an iron in the west line of the Mendenhall property; thence with Mendenhall's west line
the following two courses and distances: South 2 degrees 04 minutes 01 second West
94.84 feet to an iron and South 2 degrees 21 minutes 30 seconds West 633.70 feet to a
right-of-way monument, a corner of the Mendenhall property; thence with Mendenhall's
north line North 88 degrees 15 minutes West 711.33 feet, crossing a branch, to a
monument on the west right-of-way line of Hay Road, said monument being in the east
line of the Anderson property; thence with the Anderson east line, being the west line of
Hay Road, North 2 degrees 30 minutes East 669.95 feet to the BEGINNING, containing
11.76 acres, including 46/100 acre in the right-of-way of Hay Road, as shown on a
survey, dated April 22, 1987, by Daniel Walter Donathan, RLS #L-1192, and being a
resurvey of the property described in Book 503, Page 639; and Book 656, Page 84, in the
Office of the Register of Deeds for Davidson County, North Carolina.

K�
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
February 14, 2011
Mr. Fred P. Cox
Quail Run Mobile Home Park
P.O. Box 631
Stanleytown, VA 24168-0631
Dee Freeman
Secretary
Subject: Letter of Adequacy
Quail Run Mobile Home Park, Lot #14
NPDES Permit No. NCO070033 & Collection System Permit No. WQCSD0196
Davidson County
Dear Mr. Cox:
As per your request today, this letter serves as notice of adequacy and proper licensing for the
recirculating surface sandfilter wastewater treatment facility and the collection system that serves the
subject property at Quail Run Mobile Home Park in Davidson County, NC.
As of the date of this letter, the wastewater treatment facility and the collection system that serve
the subject property are in good condition and are properly operated. Additionally, both the wastewater
treatment facility and the collection system are properly licensed by the NC Division of Water Quality
under permit numbers NCO070033 and WQCSD0196, respectively. Our office has no concerns with
issuance of the necessary building permits so that Lot #14 can be occupied.
If you have any questions regarding this letter, please call me at [phone].
Sincerely,
Michael M. Mickey
Environmental Specialist
Surface Water Protection Section
cc: WSRO
North Carolina Division of Water Quality, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem, North Carolina 27107
Phone: [phone] \ FAX: [phone] \ Customer Service: 1-877.623-6748
Internet: www.ncwaterquality.org
Nne
orthCarolinz
Aatur AY
An Equal Opportunity \ Affirmative Action Employer

NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Mr. Fred P. Cox
Quail Run Mobile Home Park
P.O. Box 631
Stanleytown, VA 24168-0631
Division of Water Quality
Coleen H. Sullins
Director
May 27, 2010
SUBJECT: Compliance Evaluation Inspection
Quail Run Mobile Home Park WWTP
NPDES Permit No. NCO070033
Davidson County
Dear Mr. Cox:
Dee Freeman
Secretary
On April 29 2010, Ms. Jenifer Carter of the Winston-Salem Regional Office conducted a Compliance Evaluation
Inspection at Quail Run Mobile Home Park's Wastewater Treatment Facilities. Mr. Quentin Campbell, ORC, was
present during the inspection. The inspection consisted of two parts: an on -site inspection of the treatment facility
and a review of facility files and self -monitoring data.
A review of the submitted self -monitoring data for the period of March 2008 through February 2010 revealed one
Total Residual Chlorine limit violation, which has already been addressed through the Division's regular monthly
enforcement program.
With respect to the administrative portion of the facility's self -monitoring program, no deficiencies were noted.
The following is a summation of the inspection.
A) Facility records (daily logs and maintenance records) are well organized and current.
B) The audible and visual alarms both functioned properly.
C) Copies of the permit are kept on site and with the ORC.
Should you have any questions please contact Jenifer Carter in our Winston-Salem Regional Office at (336) 771-
4957.
Sincerely,
Steve W. Tedder
Surface Water Regional Supervisor
Surface Water Regional Supervisor
Winston-Salem Regional Office
attachment
cc: Quentin Campbell, ORC (3336 Beck's Church Rd; Lexington, NC 27292)
SWP-Central Files
WSRO Files
North Carolina Division of Water Quality, VVinston-Salem Regional office
Location 585 Waughtown St. Winston-Salem, Noah Carolina 27107
Phone: [phone] ! FAX: [phone] i Customer Service: 1-877-623 0748
Internet www.ncwaterquality.org
One
NorthCarolina
Naturally
An Equal opperhinity AYirmatrve Action Employer

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 I NI 2 L 31 NCO070033 111 121 10/04/29 117 181 Cl 191SI 20III
Remarks
21111111111111IIII IIIIIIII IIII IIIIII1I IIII11111116
Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 QA --------------------------- Reserved ----------------------
67 I 169 70 13 I 711 NJ 721 N I 73 I I 174 751 I I I I I I 180
_1__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)
09:30 AM 10/04/29
09/06/01
Quail Run Mobile Home Park
Exit Time/Date
Permit Expiration Date
136 Quail Pl Dr
Winston Salem NC 27127
10:15 AM 10/04/29
14/05/31
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
Other Facility Data
Quentin Lee Campbell//336-357-5398 /
'jfame Address of Responsible Official/Title/Phone and Fax Number F✓r l .Po -A(.
v (p`31
.a,'y anir.yi0<;��� VA 2-4160,Y-003i Contacted
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit Operations & Maintenance 0 Records/Reports Self -Monitoring Program
Facility Site Review Effluent/Receiving Waters
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
Jenifer Carter WSRO WQ//336-771-5000/
Signature of Manage ent Q A Revi r Agency/Office/Phone and Fax Numbers Date
y
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page # 1

Permit: NCO070033 Owner - Facility: Quail Run Mobile Home Park
Inspection Date: 04/29/2010 Inspection Type: Compliance Evaluation
Effluent Sampling Yes No NA NE
Is sample collected below all treatment units? ■ n n n
Is proper volume collected?
■
n
n
n
Is the tubing clean?
n
n
■
n
# Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees Celsius)?
n
n
■
n
Is the facility sampling performed as required by the permit (frequency, sampling type representative)?
■
n
n
n
Comment:
Upstream / Downstream Samolina
Yes
No
NA
NE
Is the facility sampling performed as required by the permit (frequency, sampling type, and sampling location)? ■ n n n
Comment:
Operations & Maintenance Yes
No
NA
NE
Is the plant generally clean with acceptable housekeeping? ■
n
n
n
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable Solids, pH, DO, Sludge n
n
■
n
Judge, and other that are applicable?
Comment:
Septic Tank Yes
No
NA
NE
(If pumps are used) Is an audible and visual alarm operational? ■
n
n
n
Is septic tank pumped on a schedule?
■
n
n
n
Are pumps or syphons operating properly?
n
n
n
■
Are high and low water alarms operating properly?
n
n
n
■
Comment: All tanks throughout the mobile home park are pumped out regularly.
They
all gravity feed to the plant.
Sand Filters (Low rate)
Yes
No
NA
NE
(If pumps are used) Is an audible and visible alarm Present and operational?
■
n
n
n
Is the distribution box level and watertight?
■
n
n
n
Is sand filter free of ponding?
■
n
n
n
Is the sand filter effluent re -circulated at a valid ratio?
■
n
Cl
n
# Is the sand filter surface free of algae or excessive vegetation?
■
n
n
n
# Is the sand filter effluent re -circulated at a valid ratio? (Approximately 3 to 1)
■
n
n
n
Comment:
Disinfection -Tablet
Yes
No
NA
NE
Are tablet chlorinators operational?
■
n
❑
Page # 4

Permit: NC0070033 Owner - Facility: Quail Run Mobile Home Park
Inspection Date: 04/29/2010 Inspection Type: Compliance Evaluation
Disinfection -Tablet
Yes
No
NA
NE
Are the tablets the proper size and type?
■
n
n
n
Number of tubes in use?
1
Is the level of chlorine residual acceptable?
■
n
n
n
Is the contact chamber free of growth, or sludge buildup?
■
n
n
n
Is there chlorine residual prior to de -chlorination?
■
n
n
n
Comment: Chlorine tablets placed in tank, not the chlorinator tubes. This has proven
effective. The chlorinator tubes were installed in such a way that did not allow proper
access.
De -chlorination
Yes
No
NA
NE
Type of system ?
Tablet
Is the feed ratio proportional to chlorine amount (1 to 1)?
■
n
n
n
Is storage appropriate for cylinders?
■
n
n
n
# Is de -chlorination substance stored away from chlorine containers?
■
n
n
n
Are the tablets the proper size and type?
■
n
n
n
Comment: Dechlor tablets placed in the effluent pump station instead of the dechlor
tubes. This has proven effective. The dechlorinator tubes were installed in such a way
that did not allow proper access.
Are tablet de -chlorinators operational?
■
n
n
n
Number of tubes in use?
Comment: see comment above
Page # 5

A ''
NCDENR
North Carolina Department of Environment and
Division of Water Quality
Beverly Eaves Perdue, Governor IColeen H. Sullins, Director
March 11, 2009
Mr. Fred P. Cox
P.O. Box 631
Stanleytown, VA 24168-0631
RECEIVED
N.0 Dect. of ENR
i
j MAR 13 20M
lWinston -
Regional Office
Natural Resources
Dee Freeman, Secretary
Subject: Draft NPDES Permit NC0070033
Quail Run MHP WWTP
Davidson County
Dear Mr. Cox:
The Division has reviewed your request to renew the subject permit. Please review this draft carefully to
ensure your thorough understanding of the information, conditions, and requirements it contains.
The draft permit includes the following significant changes from the existing permit:
➢ Anew total residual chlorine compliance level has been added [see A.(!) for details].
With this notification, the Division will solicit public comment on this draft permit by publishing a notice in
newspapers having circulation in the general Davidson County area, per EPA requirements. Please
provide your comments, if any, to me no later than 30 days after receiving this draft permit.
Following the 30-day public comment period, the Division will review all pertinent comments and take
appropriate action prior to issuing a final permit. If you have questions concerning the draft, please contact
me at the telephone number or e-mail address listed at the bottom of this page.
Sincerely,
Charles H. Weaver, Jr.
NPDES Unit
cc: Central Files
Winston-Salem Regional Office / Jenifer Carter
NPDES Unit
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
512 North Salisbury Street, Raleigh, North Carolina 27604
Phone: [phone] / FAX [phone] / Internet: www.ncwaterquality.org
[e-mail]
NorthCarolina
;Vahmallb,
An Equal Opportunity/Affirmative Action Employer — 50% Recycled/10% Post Consumer Paper

Permit NCO070033
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
PERMIT
TO DISCHARGE WASTEWATER UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provisions 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,
Fred P. Cog
is hereby authorized to discharge wastewater from a facility located at
Quail Run Mobile Home Park
136 Quail Place Drive
Winston-Salem
Davidson County
to receiving waters designated as Miller Creek in subbasin 03-07-04 of the Yadkin -Pee Dee
River Basin in accordance with effluent limitations, monitoring requirements, and other
conditions set forth in Parts I, II, III, and IV hereof.
The permit shall become effective
This permit and the authorization to discharge shall expire at midnight on May 31, 2014.
Signed this day
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission

r
Permit NCO070033
SUPPLEMENT TO PERMIT COVER SHEET
All previous NPDES Permits issued to this facility, whether for operation or discharge are
hereby revoked, and as of this issuance, any previously issued permit bearing this number is
no longer effective. Therefore, the exclusive authority to operate and discharge from this
facility arises under the permit conditions, requirements, terms, and provisions included
herein.
Fred P. Cox is hereby authorized to:
1. Continue to operate an existing 0.017 MGD wastewater treatment plant that includes the
following components:
• Two 3,200 gallon septic tanks
• One 4,000 gallon septic tank
• Two 4,500 gallon septic tanks
• 8,400 gallon recirculating dosing tank
• 4,250 square foot recirculating surface sandfilter
• Tablet chlorinator
• 350 gallon chlorine contact tank
This permitted facility is located at the Quail Run Mobile Home Park WWTP [136 Quail
Place Drive, Winston-Salem] in Davidson County.
2. Discharge from said treatment works at the location specified on the attached map into
Miller Creek, currently classified C waters in subbasin 03-07-04 of the Yadkin -Pee Dee
River Basin.

i
Permit NCO070033
A. (1) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS -
Beginning on the effective date of this permit and lasting until permit expiration, the Permittee is
authorized to discharge from Outfall 001. Such discharges shall be limited and monitored by the Permittee
as specified below:
EFFLUENT LIMITATIONS
MONITORING REQUIREMENTS
PARAMETER
Monthly Average
Daily Maximum
Measurement
Sample Type
Sample
Location
Fre uenc
Flow
0.017 MGD
Weekly
Instantaneous
Influent or
Effluent
BOD5
30.0 mg/L
45.0 mg/L
21month
Grab
Effluent
Total Suspended Solids
30.0 mg/L
45.0 mg/L
21month
Grab
Effluent
NH3-N
6.9 mg/L
34.5 mg/L
21month
Grab
Effluent
(April 1- October 31)
NHA
25.8 mg1L
35.0 mg/L
21month
Grab
Effluent
(November 1- March 31)
Dissolved Oxygen
Weekly
Grab
Effluent,
(April 1- October 31)
U & D
Fecal Coliform
2001100 ml
400/100 ml
2/month
Grab
Effluent
(Geometric Mean)
Total Residual Chlodne2
28 pg/L
21Week
Grab
Effluent
Temperature
Daily
Grab
Effluent
Temperature
Weekly
Grab
U & D
Total Nitrogen
Quarterly
Grab
Effluent
(TKN + NO2 + NOs)
Total Phosphorus
Quarterly
Grab
Effluent
pH
> 6.0 and < 9.0 Standard Units
2/month
Grab
Effluent
Notes:
1 U:upstream approximately 100 feet from the outfall. D: downstream at least 300 feet from the outfall.
2 The Permittee shall report all effluent TRC values reported by a NC -certified laboratory [including field -
certified]. Effluent values below 50 µg/L will be treated as zero for compliance purposes.
THERE SHALL BE NO DISCHARGE OF FLOATING SOLIDS OR VISIBLE FOAM IN OTHER THAN TRACE
AMOUNTS.

"JAN-04-2006 09:39 QUAIL RUN HOMES 276 6345400
Quail Run Mobile Home Park
P 0 Box 631
Stan!eytown, VA 24168
Sera to: Steve Mauney
From: Michele Cox
Date: 1 /4/2 006
Fax Number: 336-771-4630
Phone Number: 276-634-5400
O Urgent
O Reply ASAP
O Please comment
O Please Review
O For your Information
Total pages, including cover: 4
ts:
Following is the copy of the recorded right-of-way we spoke
about yesterday. Any further questions, please call me at:
276-629-8033 most afternoons after 2PM.
IMichele Cox

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m'R;h'�: _ PAdPFRTY - '.. iv wicTR•..a[i iS:_% •sti_. -' _ _ - jT _
or
kD
FREDERICK P. COX---"'��' �"=-= -... k.��`-.•— - - ..
_ --
LOT- 35
THE: SMTHERN_ PORTION -of
m THE NORT1-IERS� PD[t` O F '72
MAP ei ••.,g's -' a•� �-�a..N-� �r+�s-� �1 _ � ..
Z
Ds coBalgjt- Sam rwGt4►3� _ : c!' ` t .a n._tr,p_ "-`t V>I=ya1�.:
�' rim _ O➢4bPIDSONlCO.�._� _ -,xCE "Maid
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'' QATB: APRIL 2Yi �►to �isl - ,is: n,+11'nY�slt�
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UNITED, LTD. �.n _ �-� 1
' e . e o soe IOTA. -: LILREL�C-a'E' t" j �`:TAL REa�J F

JAN-04-2006 09=39 QUAIL RUN HOMES 276 6345400 P.02i02
MARK G. KLA=
ATTORNE V AT LAW
B WGGT FIRGT AV"Vi
6GX18wGT0N. N. C,'
27"2
4
800K f b 7
.. boy • . Sul 1, � � �
DEEii��
KNOW ALL NW BY TIM9E FOLTZ
(widower), hereinafter called eznptor; and' FRSDLRICR P. COX
et ux NIMBLA A. C=...hereinaftor called Grantees,
in consideration of.One Dollar ($1.00) and other good -and
valuable considerations, the receipt of which„Lo hereby
acknowledged, the Grantor abovL- named, doee'herfby grant and
convey unto the Grantoes above named, a right-of-way and an
easement for the purpose of constructing and using an
underground newer line in and over the following described
property situated in the county of Davidson, State of North
Carolina and more particularly described as follows:
BEING an easement leading from Hay Road and being
;.he southwest corner of the property of the parties of
the second part across the property of the party of the
first part'•to the.centes'of Millers Creek, the center
line of said easement being more particularly described
as followse (Said easement being lei feet wide at this
point) South 5 degs. 33' 35" West 379.85 feet to a
point; South 2 dego. 12' 42" Went 100.00 feet; South 14
degs. 17' 52" West 74.59 feet to a point whore said
easement widens to 14 feet; South 2 degs. 12' 10" West
175.47 feet to a point; South 4 degs 30' 12" West 140.77
feet to a point; South 2 degs. 40' 23" West 126.96 feet
to a point; South 1 deg. 05' 47" East 179.21 feet to a
point; South 27 degs. 52' 23" West 90.41 feet; South 71
deg. 06' 41" West 91.88 feet; and South 3 degs. 42' 12"
West 20.00 feet to the center of Millers Creek, as shown
on the attached survey marked Exhibit "A" by Daniel
waiter Donathan. RLS #L-1192•
NOW, TBSRZ3?ORB, said Grantor, for and in consideration
of the matters and things bereinbefore set 'forth, does hereby
give, grant and convey unto said Grantees# their heirs
and assigns, a perpetual right and an easement tu o""se saic rp%
property above described for an underground sewer line and
the right to conciruct, in.seect, and maintain a aewQr line
along said easement.
IT BEING SPECIFICALLY TJ!®ERSTOOD ADTD fiGREEO that the
purpose of this easement is to create a perpetual right and
easement for said parties, above named, for a sewer line.
TO DAVE AND TO BOLD said right and easement to the
GrantaeQ 4:reei.r, amc-noaanre A"A assicrs -
IT BRING AGRSBD that the rights herein conveyed and the
easement hereby granted is appurtenant to and runs with the
lands now owned by the Grantees hereinabove named.

JAN-04-2006 09:41
QUAIL RUN HOMES
276 6345400 P,01/02
E
il�o r�o
MARK E. KLASS
ATTORNEY AT LAW
S WUT FIRST AveNUE
LEXINGTON. N. C.
29292
The sight -of -way and easement hereby granted shall be
binding upon and shall inure to the parties hereto, their
succdasors, heirs and assigns.
IN WITR= WMEOF, the Grantor has.hereunto set his
hand and seal, this the day of '19870.
A. A. POLTZ
NORTH CAROLINA
DAVIDSON COUNTY
it S.hi�/ea ��a�+�✓ , notary public of
said county anted state, do hereby acknowledge that A. A. FOLTZ
(widower) personally appeared before me this day and
acknowledged the execution of the foregoing instrument.
WITNESS my hand and notarial seal, this the SAit day of
1987.
/..�► �/ r (SEAL)
s•:''v " NOTARY PUBLIC
commission expires:
3a 1110
Nam CarvEea-cavibsan
.. ... � 1 Ca• .1 i:19+i% "r' .�i��.,. _y1R_11 ._. L� .�.... n. •.�._ . � .. ..
.q.O�i \ V •�•1) \ISM \"..._. .• .. ... ... • r• r
L„1
Rana` vv. ",tcu.,

Mr. Fred Cox
Quail Run Mobile Home Park
P.O. Box 631
Stanleytown, Virginia 24168
Dear Mr. Cox:
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
October 6, 2005
OCT 10
I w 203
naton
Regional Q!fice
SUBJECT: Authorization to Construct
A to C No. 070033AOI
Quail Run Mobile Home Park WWTP
Dechlorination Facilities
Davidson County
A fast track application for Authorization to Construct dechlorination facilities was
received on September 29, 2005, by the Division. Authorization is hereby granted for the
construction of modifications to the existing Quail Run Mobile Home Park WWTP, with
discharge of treated wastewater into Miller Creek in the Yadkin -Pee Dee River Basin.
This authorization results in no increase in design or permitted capacity and is awarded
for the construction of the following specific modifications:
Installation of a tablet dechlorination system pursuant to the fast track application
received on September 29, 2005, and in conformity with the Minimum Design
Criteria for Dechlorination Facilities.
This Authorization to Construct is issued in accordance with Part III, Paragraph A of
NPDES Permit No. NCO070033 issued May 1, 2005, and shall be subject to revocation unless
the wastewater treatment facilities are constructed in accordance with the conditions and
limitations specified in Permit No. NC0070033.
In the event that the facilities fail to perform satisfactorily, including the creation of
nuisance conditions, the Permittee shall take immediate corrective action, including those as may
be required by this Division, such as the construction of additional or replacement wastewater
treatment or disposal facilities.
The Winston-Salem Regional Office, telephone number [phone], shall be notified
at least forty-eight (48) hours in advance of operation of the installed facilities so that an on site
NNam`hCarolina
aturally
North Carolina Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 Phone [phone] Customer Service
Intemet: h2o.enr.state.nc.us 512 N. Salisbury St. Raleigh, NC 27604 FAX [phone]
An Equal Opportunity/Affirmative Action Employer — 50% Recycled/10% Post Consumer Paper

Mr. Fred Cox
October 6, 2005
Page 2
inspection can be made. Such notification to the regional supervisor shall be made during the
normal office hours from 8:00 a.m. until 5:00 p.m. on Monday through Friday, excluding State
Holidays.
Pursuant to 15A NCAC 2H .0140, upon completion of construction and prior to operation of
these permitted facilities, the completed Engineering Certification form attached to this permit shall be
submitted to the address provided on the form.
Upon classification of the facility by the Certification Commission, the Permittee shall
employ a certified wastewater treatment plant operator to be in responsible charge (ORC) of the
wastewater treatment facilities. The operator must hold a certificate of the type and grade at least
equivalent to or greater than the classification assigned to the wastewater treatment facilities by
the Certification Commission.
The Permittee must also employ a certified back-up operator of the appropriate type and
grade to comply with the conditions of T15A:8G.0202. The ORC of the facility must visit each
Class I facility at least weekly and each Class 1I,11I and IV facility at least daily, excluding
weekends and holidays, must properly manage the facility, must document daily operation and
maintenance of the facility, and must comply with all other conditions of TI5A:8G.0202.
A copy of the approved plans and specifications shall be maintained on file by the
Permittee for the life of the facility.
During the construction of the proposed additions/modifications, the permittee shall
continue to properly maintain and operate the existing wastewater treatment facilities at all times,
and in such a manner, as necessary to comply with the effluent limits specified in the NPDES
Permit.
You are reminded that it is mandatory for the project to be constructed in accordance
with the North Carolina Sedimentation Pollution Control Act, and, when applicable, the North
Carolina Dam Safety Act. In addition, the specifications must clearly state what the contractor's
responsibilities shall be in complying with these Acts.
Failure to abide by the requirements contained in this Authorization to Construct may
subject the Permittee to an enforcement action by the Division of Water Quality in accordance
with North Carolina General Statute 143-215.6A to 143-215.6C.
The issuance of this Authorization to Construct does not preclude the Permittee from
complying with any and all statutes, rules, regulations, or ordinances which may be imposed by
other government agencies (local, state, and federal) which have jurisdiction.

Mr. Fred Cox
October 6, 2005
Page 3
If you have any questions or need additional information, please do not hesitate to contact
Cecil G. Madden, Jr., P.E. at telephone number [phone].
Sincerely,
l
Alan W. Klimek, P.E.
MH/cgm
cc: Dennis Herzing, P.E. — R&A Engineering, Inc.
Davidson County Health Department
Winston-Salem Regional Office, Surface Water Protection Section
Technical Assistance and Certification Unit
Daniel Blaisdell, P.E.
Point Source Branch, NPDES Program
Cecil G. Madden, Jr., P.E.
Mark Hubbard, P.E.
A to C File