NCG550365_Regional Office Historical File Pre 2016

d°
NC®ENR
Borth Carolina Department of Environment and natural Resources
Pat McCrory
Governor
April 17, 2014
Mrs. Ruby H. Anderson
2049 Bethlehem Church Road
Reidsville, NC 27320
Subject: Compliance Evaluation Inspection
Certificate of Coverage: NCG550365
2049 Bethlehem Church Road
Rockingham County
Dear Mrs. Anderson:
John E. Skvarla, III
Secretary
On April 16, 2014, Jenny Graznak of this office performed a Compliance Evaluation Inspection on the
wastewater treatment system for the single family residence located at 2049 Bethlehem Church Road,
Reidsville, NC, for which you are the owner. You hold a Permit to discharge domestic wastewater from this
system. You were present during the inspection.
The inspector observed risers for the septic and dosing tanks, two chlorinator tubes, and the effluent pipe
with step aeration. As you explained during the inspection, this is a brand new system that was installed 5
years ago when the old system corroded. No discharge was observed on the day of the inspection. You stated
that the septic tank was last pumped out in January 2013, and that you rarely see discharge at the effluent
pipe. You also stated that you add chlorine sticks to the chlorinator tubes on a monthly basis.
Please be aware that the Permit requires that the septic tank contents be pumped out every five years to
prevent solids from clogging the sandfilter. The Permit also requires that the chlorinator be adequately
supplied with chlorine tablets for proper operation. A copy of all of the Permit .requirements, including
monitoring requirements, is attached to this letter. If you have. any questions regarding this permit, please
contact Ms. Graznak at [phone].
Sincerely,
Sherri V. Knight, P.E., Assistant Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDENR
Division of Water Resources
585 Waughtown Street, Winston-Salem, North Carolina 27107
Phone: [phone] Internet: www.ncwater.org
An Equal Opportunity 1 Affirmative Action Employer — Made in part by recycled paper

Permit: NCG550365 Owner - Facility: 2049 Bethlehem Church Road
Inspection Date: 04/16/2014 Inspection Type: Compliance Evaluation
Permit
(If the present permit expires in 6 months or less). Has the permittee submitted a new application?
Is the facility as described in the permit?
# Are there any special conditions for the permit?
Is access to the plant site restricted to the general public?
Is the inspector granted access to all areas for inspection?
Comment: The inspector observed risers for the septic and dosing tanks, two
chlorinator tubes, and the effluent pipe with step aeration. As you explained during the
inspection, this is a brand new system that was installed 5 years ago when the old
system corroded. No discharge was observed on the day of the inspection. You stated
that the septic tank was last pumped out in January 2013, and that you rarely see
discharge at the effluent pipe. You also stated that you add chlorine sticks to the
chlorinator tubes on a monthly basis.
Yes No NA NE
0 0 M 0
01100
0 M 0 0
0000
■nnn
Page # 3

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 15 I. 3,1 NCG550365 111 121 14/04/16 117 181 C I 19I S I 20I I
Remarks
21111111111.111IIIIIIIIIIIIIIII IIIIIIII IIIIIIII1116
Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 GA ------------- - --- Reserved-------------
67 I 169 70131711 I 72 I N I 73 W 74 . 75I III I I 1180
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)
2049 Bethlehem Church Road
11:30 AM 14/04/16
- 13/08/01
Exit Time/Date
Permit Expiration Date
2049 Bethlehem Church Rd
Reidsville NC 27320
12:00 PM 14/04/16
18/07/31
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
Other Facility Data
Name, Address of Responsible Official/Title/Phone and Fax Number
Contacted
Ruby H Anderson,2049 Bethlehem Church Rd Reidsville NC 27320//336-623-9160/ Na
Section Q Areas Evaluated During Inspection (Check only those areas evaluated)
Permit
Section D: Summary of Find in/Comments Attach additional sheets of narrative and checklists as necessary)
(See attachment summary)
Name(s) and Signature(s) of Inspector(s) Agency/Office/Phone and Fax Numbers Date
Jennifer F Graznak WSRO WQ//336-771-5000/
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
%ayt-i V. PAtgk+ COsP0 wQ II 33(p -_??I-_Z0D 'q (I-) I�1�
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page # 1

NPDES yr/mo/day Inspection Type 1
3 NCG550365 I11 12I 14/04/16 117 18I CI
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
Page # 2

.I A •
/ Zed
PermitteeL
Permit # A) cC .SS L0 3� S
Location Address �2 0 A en,
A) : C_
Contact Person '�4�4.
Phone #
Inspector
County 919 _'.
Date Inspected Z a
Self -monitoring Records---Yes---No
Chlorinator Present---g)--No
Chlorine Tablets --- Yes-- '&
Did Home Owner know of System- es�--No Cascade Aeration --- Yes --- fo
Age of System — Discharge Pipe Found---Yes--(9�
Last Repaired
Last Time Tank Pumped
Sample Taken --- Yes--&1
Sewer Yes--61111
Taken---Yes---to
General observation/Stream Condition/Inspection Summary/Description of System:
February 3,2000

e��
NCDENR
9 ?J
il�=sTiUi`tgj iyf � `�
North Carolina Department of Environment and Natural Resources
Division of Water -Quality
Michael F. Easley, Governor William.G. Ross, Jr., Secretary
Coleen H. Sullins, Director.
July 27, 2007
Ruby H. Anderson
2049 Bethlehem Church Rd
Reidsville, NC 27320
Subject: Renewal of coverage / General Permit NCG550000'
2049 Bethlehem Church Road
Certificate of Coverage NCG550365
Rockingham County
Dear Permittee:
In accordance with your renewal application [received on January 19, 20071, the Division is renewing
Certificate of Coverage (CoC) NCG550365 to discharge under NCG550000. This CoC is issued pursuant to the
requirements of North Carolina General Statue 143-215.1 and the Memorandum of Agreement between North
Carolina and the US Environmental Protection agency dated May 9, 1994 [or as subsequently amended].
If any parts, measurement frequencies or sampling requirements contained in this General Permit are
unacceptable to you, you have the right to request an individual permit by submitting an individual permit
application. Unless such demand is made, the certificate of coverage shall be final and binding.
Please take notice that this Certificate of Coverage is not transferable except after notice to the
Division. The Division may require modification or, revocation and re issuance of the certificate of coverage.
Contact the Winston-Salem Regional Office prior to any sale or transfer of the permitted facility.
Regional Office staff will assist you in documenting the transfer of this CoC.
This permit does not affect the legal requirements to obtain other permits which may be required by
the Division of Water Quality or permits required by the Division of Land Resources, Coastal Area
Management Actor any other Federal or Local governmental permit that may be required.
If you have any questions concerning the requirements of the General Permit, please contact Toya
Fields [919 733-5083, extension 551 or [e-mail] or Susan Wilson [919 733-5083, extension 510
or [e-mail]:
Sincerely,
for Coleen H. Sullins
cc: Central Files
N-PDES file
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
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper
NorthCarohna
Naturally

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NCG550000
CERTIFICATE OF COVERAGE NCG550365
DISCHARGE OF DOMESTIC WASTEWATER FROM SINGLE FAMILY RESIDENCES AND
OTHER 100% DOMESTIC DISCHARGES WITH SIMILAR CHARACTERISTICS UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful standards and
regulations promulgated and adopted by the North Carolina Environmental Management Commission, and -
the Federal Water Pollution Control Act, as amended,
Ruby H. Anderson
is hereby authorized to discharge domestic wastewater [450 GPD] from a facility located at
2049 Bethlehem Church Road
Reidsville
Rockingham County
to receiving waters designated as an unnamed tributary to Town Creek (Sharps Lake) in
subbasin 03-02-03 of the Roanoke River Basin in accordance with the effluent limitations,
monitoring requirements, and other conditions set forth in Parts I, II, III and IV hereof.
This certificate of coverage shall become effective August 1, 2007.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day July 27, 2007.
for Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Michael F..Easley,.Governor
Ruby Anderson
2049 Bethlehelm Church Rd
Reidsville, NC- 27320 -
Dear Permittee:
William G. Ross, Jr., Secretary
Alan W. Klimek, P.E., Director
January 9, 2007
Subject: 'Renewal Notice / General Permit NCG550000
Certificate of Coverage NCG5503.65
Rockingham County.
You are receiving this notice because you currently own a property covered under the subject
General Permit for the discharge of domestic wastewater. NCG550000 will expire on July 31, 2007.
Federal (40 CFR 122.41) and North Carolina (15A NCAC-2H.0105(e)) regulations require
that permit renewal applications be filed at least 180 days prior to expiration of the current permit.
To satisfy this requirement; the Division must receive a renewal request postmarked no later than
February 1, 2007.
The Certificate of Coverage (CoC) specific to your property was last issued on August 1, 2002.
The. Division needs information from you to determine if coverage under NCG550000 is still
necessary.
➢ If your property still has a wastewater system like the ones described in the enclosed
Technical Bulletin, you must_ renew the subject CoC. Complete the enclosed form and
submit it to the address on the form.
➢ If you are not sure what type of system your property has, contact David Russell in the
NC DENR Winston-Salem Regional Office at. That person [or other staff members] can
help you determine if you should renew your CoC.
➢ If you know that your property no longer discharges wastewater, contact me at the
address or phone number listed below to request rescission of the CoC.
➢ This information request does not -pertain to the Annual Fee of $50.00 billed
separately by the Division's Budget Office. No money is required for this
procedure. The Annual.Fee is like the fee. you annually pay the DMV for the sticker on..
your vehicle's license plate. Renewal of your CoC is like the renewal of your Driver's
License [ca. every five years].
➢ If you have already mailed a renewal request, you may disregard this notice.
1617 Mail Service Center, Raleigh, North Carolina .27699-1617 One
512 North Salisbury Street; Raleigh, North Carolina 27604 NOY thCdT'01111a
Phone:.[phone], extension 511 / FAX [phone]/cha'[e-mail] Naharally
An Equal Opportunity/Affirmative Action Employer — 50% Recycled/10% Post Consumer Paper

NCG550365 renewal notice
January 9; 2007
_<
The attached application form shows the information the Division has on file for your
property. Please verify that the provided information is correct, or make corrections on the form.
Complete the additional questions, then sign and date the form.
The completed form should be submitted to the address listed below the signature block.
If you have any questions concerning this matter, please contact me at the telephone number
or e-mail address listed below. (If it is difficult to reach me, please be aware that your facility is one
of over 1100 that I am contacting regarding the renewal of NCG550000.)
Thanks for your attention to this matter.
Sincerely,
�' lV
Charles H. Weaver, Jr.
NPDES Unit
cc: Central Files
NPDES file

- State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
Michael F. Easley, Governor
William G. Ross Jr., Secretary
Alan W. Klimek, P.E., Director
JAMES ROGEERSON
ANDERSO"H-SFR
2049 BETHLEHELM CHURCH RD
REIDS VILLE, NC 27320
!Liam
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
RECEIV�`
July 26, 2002 N. C. Dep- , ctF EHNRR
J U L 3 9 2902
W ii1t>t ,-S,a1ern
Re dic? la1. �.�'F,licla:
Subject: Reissue - NPDES Wastewater Disch'drge Permit
Anderson Ruby H - SFR
COC Number NCG550365
Rockingham County
Dear Permittee:
In response to your renewal application for continued coverage under general permit NCG550000, the Division of
Water Quality (DWQ) is forwarding herewith the reissued wastewater general permit Certificate of Coverage
(COC). This COC is reissued pursuant to the requirements of North Carolina General Statute 143-215.1 and the
Memorandum of Agreement between the state of North Carolina and the U.S. Environmental Protection Agency,
dated May 9, 1994 (or as subsquently amended).
The following information is included with your permit package:
* A copy of the Certificate of Coverage for your treatment facility
* A copy of General Wastewater Discharge Permit NCG550000
* A copy of a Technical Bulletin for General Wastewater Discharge Permit NCG550000
Your coverage under this general permit is not transferableexcept after notice to DWQ. The Division may require
modification or revocation and reissuance of the Certificate of Coverage. This permit does not affect the legal
requirements to obtain other permits which may be required by DENR or relieve the permittee from responsibility
for compliance with any other applicable federal, state, or local law rule, standard, ordinance, order, judgment, or
decree.
Please note that effective January 1, 1999 the fees for all permits issued by DWQ were changed. This changed the
fee for your wastewater general permit coverage from a $240 fee paid once every five years to a yearly fee of $50.
If you have not already been billed this year for the yearly fee, you will receive a bill later this year.
If you have any questions regarding this permit package please contact Mack Wiggins of the Central Office
Stormwater and General Permits Unit at [phone], ext. 542
Sincerely,
for Alan W. Klimek, P.E.
cc: Central Files
Stormwater & General Permits Unit Files
Winston-Salem Regional Office
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post -consumer paper

W AT F9QG
r
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 26, 2004
Ruby H Anderson
or Current Owner
2049 Bethlehelm Church Rd
NC, 27320 [phone]
Subject: NPDES General Wastewater Permit No. NCG550365
Single Family Residence at 2049 Bethlehelm Church Rd
Rockingham County
Dear Ruby H Anderson:
Our office would like to remind you that you hold General Permit No. NCG550365 to discharge
Domestic Wastewaters from Single Family Residences under the National Pollutant Discharge
Elimination System (NPDES). Please be advised that you are required to comply with all conditions of
this permit. Under state law, a daily civil penalty of not more than twenty-five thousand dollars ($25,000)
per violation may be assessed against any person who violates or fails to act in accordance with the terms,
conditions, or requirements of a permit. [Ref: NC General Statutes 143-215.6A]
Please read and familiarize yourself with the conditions of the permit. Permit text Part I Section A
specifies the limits and monitoring requirements. The entire Permit text can be viewed at this website:
http://h2o.enr.state.nc.us/su/PDF FilesANW General Permits/NCG55 Permit 2002.pdf . The following
effluent parameters must be monitored on an annual basis: Flow, Biochemical Oxygen Demand (BOD),
Total Suspended Residue, Fecal Coliform, and Total Residual Chlorine. Please refer to the permit text for
specific effluent limitations. A Laboratory with North Carolina Wastewater Certification must perform
the monitoring. A list of certified labs is available from our office upon request. You must also conduct
and document the following maintenance activities on the system:
- Septic tanks shall be maintained at all times to prevent seepage of sewage.
- Septic tanks will be checked at least yearly to determine if solids must be removed.
- Septic tanks shall be pumped out within 3-5 years of issuance date of the Permit.
- Contents removed from septic tanks shall be disposed of at a location and in a manner compliant with
all local and state regulations.
- Surface sand filters and disinfection apparatus shall be inspected weekly.
All records pertaining to the permit shall be retained for at least 3 years from the date of sample,
measurement, report or application. Should you have any questions concerning this letter, please contact
me at [phone]. If the abovementioned property and wastewater treatment system has changed
ownership, please call our office to request a Permit Name Change Form. Thank you for your attention to
this matter.
Si rrely,
Winston Salem Regional Office
Division of Water Quality
cc: Central Files
'WSRO-,
No `hCarolina
;aturally
North Carolina Division of Water Quality 585 Waughtown Street Winston Salem, NC 27107 Phone [phone] FAX [phone]
Internet: h2o.enr.state.nc.us
An Equal Opportunity/Affirmative Action Employer — 50% Recycled/10% Post Consumer Paper

State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
Michael F. Easley, Governor
William G. Ross Jr., Secretary
Gregory J. Thorpe, Ph.D., Acting Director
11 /26/01
JAMES ROGER ANDERSON
ANDERSON JAMES R- RESIDENCE
2049 BETHLEHELM CHURCH RD
REIDSVILLE, NC 27320
1�•
NCD-ENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
Subject: NPDES Wastewater Permit Coverage Renewal
Anderson James R- Residence
COC Number NCG550365
Rockingham County
Dear Permittee:
Your residence or facility is currently covered for wastewater discharge under General Permit NCG550000. This
permit expires on July 31, 2002. Division of Water Quality (DWQ) staff is in the process of rewriting this permit
with a scheduled reissue in the summer of 2002. Once the permit is reissued, your residence or facility would be
eligible for continued coverage under the reissued permit.
In order to assure your continued coverage under the general permit, you must apply to the DWQ for renewal of
your permit coverage. To make this renewal process easier, we are informing you in advance that your permit will
be expiring. Enclosed you will find a general permit coverage renewal application form. This will serve as
your application for renewal of your permit coverage. The application must be completed and returned with the
required information by February 01, 2002 in order to assure continued coverage under the general permit. There is
no renewal fee associated with this process.
Failure to request renewal within this time period may result in a civil assessment of at least $250.00. Larger
penalties may be assessed depending on the delinquency of the request. Discharge of wastewater from your
residence or facility without coverage under a valid wastewater NPDES permit would constitute a violation of
NCGS 143-215.1 and could result in assessments of civil penalties of up to $10,000 per day.
If the subject wastewater discharge to waters of the state has been terminated, please complete the enclosed
rescission request form. Mailing instructions are listed on the bottom of the form. You will be notified when the
rescission process has been completed.
If you have any questions regarding the permit coverage renewal procedures please contact the Winston-Salem
Regional Office at 336-771-4600 or Mack Wiggins of the Central Office Stormwater Unit at [phone], ext.
542
Sincerely,
Bradley Bennett, Supervisor
Stormwater and General Permits Unit
cc: Central Files
Stormwater and General Permits Unit Files
Winston-Salem Regional Office
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post -consumer paper

.6
Permittee��`�
Permit #-5cJ�3�_
Location Address��,,_�
cx\
Contact Person '�WS .
P h o ne
v
Inspector
County
Date Inspected`
Self -monitoring Records --- Yes--4 )
Chlorinator Present--- es --No
Chlorine Tablets---Yes---No
Did Home Owner know of System-�e --No Cascade Aeration-- Yes --No
Age of System-���� "�� Discharge Pipe Found-- Des
-No
Last Rep is red Sample Taken ---Yes- -No
Last Time Tank Pumped �,. Sewer Available --- Yes-O-No
Pictures Taken---Yes-o
General observation/Stream Condition/Inspection Summary/Description of System:
February 3,2000

,` NPDES FACILITY AND PERMIT DATA 11/08/01 14:07:48
� RETRIEVE OPTION, TRXID 6NU KEY NCG550365
PERSONAL DATA FACILITY APPLYING FOR PERMIT REGION
FACILITY NAME> ANDERSON, JAMES R. - RESIDENCE COUNTY> ROCKINGHAM 04
ADDRESS: MAILING (REQUIRED) LOCATION (REQUIRED)
STREET:'2049 BETHLEHELM CHURCH RD. STREET: 2049 BETHLEHELM CHURCH RD.
CITY: REIDSVILLE ST NC ZIP 27320 CITY: REIDSVILLE ST NC ZIP 27320
TELEPHONE [phone] DATE FEE PAID: 03/24/97 AMOUNT: 240.00
STATE CONTACT> WEAVER PERSON IN CHARGE JAMES ROGER ANDERSON
1=PROPOSED,2=EXIST,3=CLOSED 2 1=MAJOR,2=MINOR 2 1=MUN,2=NON-MUN 2
LAT: 3627150 LONG: 07942570 N=NEW,M=MODIFICATION,R=REISSUE> R
DATE APP RCVD 03/24/97 WASTELOAD REQS 08/28/91
DATE STAFF REP REQS 08/28/91 WASTELOAD RCVD 08/28/91
DATE STAFF REP RCVD 09/10/91 SCH TO ISSUE 11/15/91
DATE TO P NOTICE 10/01/91 DATE DRAFT PREPARED 09/11/91
DATE OT AG COM REQS / / DATE DENIED
DATE OT AG COM RCVD / / DATE RETURNED
DATE TO EPA / / DATE ISSUED 07/21/97 ASSIGN/CHANGE PERMIT
DATE FROM EPA / / EXPIRATION DATE 07/31/02
FEE CODE ( 5 ) 1=(>IOMGD),2=(>1MGD),3=(>0.1MGD),4=(<0.1MGD),5=SF,6=(GP25,64,79),
7=(GP49,73)8=(GP76)9=(GP13,34,30,52)0=(NOFEE) DIS/C 04 CONBILL ( )
COMMENTS: FORMERLY NC0063517
MESSAGE:

S.tat&of North Carolina s'
bepartment of Environment,
Health, and Natural Resources
Divisi'on of Environmental Management
James B. Hunt, Jr., Governor .
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
JAMES ROGER ANDERSON
ANDERSON RESIDENCE (JAMES R.)
ROUTE 9, BOX 159B-B(FORESTDALE
REIDSVILLE NC 27320
Dear Permittee:
September 30,1993
®FEHNF=t
RECEIVED
Dept.I
11ZFn � R 103
Subject: ANDERSON RESIDENCE (JAMES R.)
Certificate of Coverage NCG550365
General Permit NCG550000
Formerly NPDES Permit NC0063517
Rockingham County
The Division of .Environmental Management has recently evaluated all existing individual permits for potential
coverage under general permits currently issued by the Division. 15A N.C.A.C. 2H .0127 allows the Division to
evaluate groups of permits having similar discharge activities for coverage under general permits and issue
coverage where the Division finds control of the discharges more appropriate in this manner. The Division has
determined that the subject discharge qualifies for such coverage. Therefore, the Division is hereby issuing the
subject Certificate of Coverage under the state-NPDES general permit no. NCG550000 which shall void NPDES
Permit NC0063517. This Certificate of Coverage is issued pursuant to the requirements of North Carolina and the
US Environmental Protection Agency Memorandum of Agreement dated December 6,1983 and as subsequently
amended.
If any parts, measurement frequencies or sampling requirements contained in this general permit are unacceptable to
you, you have the right to submit an individual permit application, associated processing fee and letter requesting
coverage under an individual permit. Unless such demand is made, this decision shall be final and binding. Please
take notice this Certificate of Coverage is not transferable. Part II, E.4. addresses the requirements to be followed
in case of change of ownership or control of this discharge.
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. Construction of any
wastewater treatment facilities will require issuance of an Authorization to Construct from this Division.
Failure to abide by the requirements contained in this Certificate of Coverage and respective general permit may
subject the Permittee to an enforcement action by the Division of Environmental Management in accordance with
North Carolina General Statute 143-215.6A to 143-215.6C. Please note that the general permit does require
monitoring in accordance with federal law. The monitoring data is not required to be submitted to the Division
unless specifically requested, however, the permittee is required to maintain all records for a period of at least
three (3) years.
Post Office Box 29535, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled -10% post -consumer paper
i

PagP2
JAMES" ROGER ANDERSON
ANDERSON RESIDENCE (JAMES R.)
Certificate, of Coverage No. NCG550365
The: issuance of this Certificate of Coverage is an administrative action initiated by the Division of
Environmental Management and therefore, no fees are due at this time. In accordance with current rules, there
are no, annual administrative and compliance monitoring fees for coverage under general permits. The only fee
you wilbe responsible for is a renewal fee at the time of renewal. The current permit expires July 31,1997.
This coverage will remain valid through the duration of the attached general permit. The Division will be
responsible for the reissuance of the general permit and at such time, you will be notified of the procedures to
follow to; continue coverage under the reissued permit. Unless you fail to follow the procedures for continued
coverage, you will continue to be permitted to discharge in accordance with the attached general permit.
The issuance of this Certificate of Coverage does not preclude the Permittee from complying with any and all
statutes, rules, regulations, or ordinances which may be required by the Division of Environmental Management
or permits required by the Division of Land Resources, the Coastal Area Management Act or any Federal or
Local other governmental permit that may be required.
If you have any questions or need additional information regarding this matter, please contact either the
Winston-Salem Regional Office, Water Quality Section at telephone number 919/ 896-7007, or a review engineer
in the NPDES Group in the Central Office at telephone number 919/733-5083.
Si erely,
�A. Preston Howar , P.E.
cc: Winston-Salem Regional Office
Central Files
I

STATE OF NORTH.CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
DIVISION OF ENVIRONMENTAL MANAGEMENT \1
GENERAL PERMIT NO. NCG550000
CERTIFICATE OF COVERAGE No. NCG550365
TO DISCHARGE TREATED DOMESTIC WASTEWATERS FROM SINGLE FAMILY RESIDENCES AND
SIMILIAR WASTEWATERS UNDER THE
NATIONAL POLLUNTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful standards and
regulations promulgated and adopted by the North Carolina Environmental Management Commission, and the
Federal Water Pollution Control Act, as amended,
ANDERSON RESIDENCE (JAMES R.)
is hereby authorized to discharge treated domestic wastewater from a facility located at
ANDERSON RESIDENCE (JAMES R.)
Rockingham County
to receiving waters designated as the UT TOWN CREEK/ROANOKE RIVER BASIN
in accordance with the effluent limitations, monitoring requirements, and other conditions set forth in Parts I, II,
III and IV of General Permit No. NCG550000 as attached.
This certificate of coverage shall become effective November 1, 1993.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day, September 30,1993.
A. Preston Howar3, Jr., P.E.,Director
Division of Environmental Management
By Authority of the Environmental Management Commission

f •' R
Water llual.ity ~action
Winston-Salem Regional Office
8003 Silas Creek Parkway Extension
-Winston-Salem,.N.C. 27106
REPORT OF Site Evaluation
Place visited James Roger Anderson
AddRoute 8, Box 159B-B
re s
`T. Gray Hauser, Jr.
By Whom
Date July
River Basin Roanoke
'Time Spent 1 Hour
PersoaS Contacted Joe Hinton, Rockingham Co. Health Dept.
Reason for Visit Site evaluation prior rn iss,faaco of NPPES Permit.
Copies to:Dale Overcash, Permits and Engineering f
Rockingham County Health Dept.
WSROr
REPORT: The following Staff Report and Recommendations pertain to the site evaluation
conducted at Anderson residence on Bethlehem Church Road, Rockingham
County.
Part I INSPECTION OF EXISTING "WASTEWATER TREATMENT SITE
1. Location: (Directions .to Facility):
From W-S, take US 158E to US 220N to
NC135 to Truck Route NC770E (Harrington Hwy) around Eden. Turn right off
Harrington Hwy. onto Bethlehem Church Road, follow it over NC 14, past gas
pipeline and Forestdale Dr. House is on left.
USGS Map Extract"Included, Map Sheet B 20 NW
Discharge Point: Latitude 36° 27 15
Longitude 790 42 ' 56
Ekevation MSL 650 Ft.

-L-
2. Bearing and Distance to Discharge Point:
Northeast corner of lot within 20 foot wide drainage easement, about
80 feet from house.
3.• Size:(Land Available for Expansion and Upgrading):
Less than 5 arra
4. Topography (Relationship -to Flood Plain Included):
Steep a)npp, nn flnnd pinino
5. Location of Nearest Dwellings (Within 1000' minimum):
Houses are on ei tbpr s; tiPgn.l hp7,;,,tj -1 n, � �.orodiqchagge is uronosed
r
6. Receiving Surface Watdr:
a. Name Ditch tributary to Town Creek
b. Classification C
C. River Basin & Subbasin No. Roanoke, 03--02--03
d. Describe receiving stream features & downstream uses
Drainage way is located in 20' drainage easement through suburban
residential development.
PART II DESCRIPTION OF EXISTING TREATMENT SYSTEM
1. Treatment Plant (Be Thorough and Include a Process Schematic):

a
is removed b e
Describe sludge handling and disposal scheme; Sludge y
licensed septic tank contractor for proper disposal as necessary.
2. Population/Processes Served (For industry, indicate production schedule;
continuous, S day-16 hr., etc.)''
Three bedroom house
3. Influent & Effluent Characterization and Operating Condition (See Attached
Data Summary) :
NA
4. WWTP Operator in Responsible Charge:
Name NA. Operator Certificate
PART III OTHER PERTINENT INFORMATION
1. Monitoring Changes: NA
2. Source of Water Supply: Public Water System
3. Other:

PART IV EVALUATION AND RECOMMENDATIONS
A. Evaluation: This house is part of the Forestdale Development which is
J
located on steep terrain and shallow poor soil. The nitrification lines
are failing and septage has surfaced in the back yard. Septage is
surfacing from the system on the adjacent lot. Many other nitrification
lines in this development have failed and many more are expected to
fail in the future. The proposed discharge is'into a dry ditch
within a drainage easement across the lot.
1
r
B. Recommendations (Include,Proposed Special Permit Provisions):
I recommend a discharge permit be issued with the following monthly average
limits:
Flow - 450 GPD
BOD -- 15 mg/1
NH3-N - 4 mg/1
D.O. - 6 mg/1
pH - 6-8.5 S.U.
Fecal Coliform - 1000#/100 ml
TSS - 30 mg/l
A letter from Rockingham County Health Dept. stating - that ground absorption
system is not possible should be requited. ;

Date: Jti//
Fac i i , ty Name: t.: /1/C00 G 3S/
Receiving Class. Sus-_;zaS;r.: U3-0;z-03
coUrty: �loAo,.n �egier,a; C"ice:_
s4�e lit/, r!S / (� h -
> efere-.ce US _ :duao: /3 zo _x,s••;ng: rrCPOs�::
I evat , cn 6S6 Dra n5cF Area: • V,5- ,"',
Hyd r 0 :cc. z _r... P� s^sera. .2
C v .
45- e
(✓ 745 )
a sy
Spa
/.aa0
y�
4 ve •��/�
S/a�Je
/ G 6 FPS
COmme, , s -
�Q/�= 0.O.3/sic
RECOMMENDED EFFLUENT L !!N"ITS
4SC7
NH3-N
(Mg
D.0.
ingli):
H.
(SU)
Fecal Cc i
: 300Mi):
/000
TSS
(Mg/ I) :
30
IRECOMMENDED BY: �.�- ,,.Z Da t e
APPROVED BY:
flegiona.l Engineer: Date: —
Regional Supervisor: Date:%--22 -�
;t 'ROUTE to Technical. Support Group and Permits & Engineering Unit.
aEncio�as .
T 9r copy of USGS- fopographlc-&I map-eshowing location of discharger)

• �li 1Cem -�. � � i ;' - --� ) " � boo
k�,, 02
Se.. ��� i ..�.-/J�,l/oC G•., 1� (� ;:I
v� �
Gla/5o,
Ra�ho�e�
o �w O ��
-757
INN
'• ---( `��/_ �'. l =� ��.��� � :� ., ///III � �i /
; (: s
�,'•
—70
J. ����� - •� i� � Jn -. � �� � _mil/ � -S�
8.39
goo--^ ✓ /�- `;\.0�--1�v-Jia� � ,'� .��� � �' :li���l � `' �,�:� 1
�• / ,% ; /, �; .,'-1, Sao /.•• o `�� `� j 1--��_I��
,r

State of North Carolina
Department of Natural Resources and Community De
512 North Salisbury Street • Raleigh, North Carolina 27611
James G. Martin, Governor
Ar. Jb. er k,eo. 4Adee$nK
k"fe 9, B®k J1558-8
Re"dsdife , ^IC.
Dear lAr. J�Je__5vk
Ta.(5 3, f5?s'
/Z �yy��ARMEIVEI�
N,C, Dept. N,RCD
'A
� \y'ltbhmental Managem;rnt
Lijstoii=Salerrm Reg, Offc-C!
S. Thomas Rhodes, Secretary
ASSIGNED TO T 6�- d
DUE DATE
Subject: Application for _NPDES Permit No. &-aorols17
'_TFw—S �S� �ite�erSnw kC;JeACe
X"k:T 4.h County `
Receipt of the fdllowing documents is hereby acknowledged:
Application. Form
Engineering Proposal (for proposed control facilities)
Request for permit renewal
Other_ /4op
If any of the items listed below are checked, the application received is in-
complete and the indicated.item(s) must be received before review can begin:
Application Form (copies enclosed)
Engineering Proposal (See (b) 1-5 on attached) Other 4#e, a. (ow.k, lqelff4 AQof. eleRU I at4 tintt,.%J o tef o�Afi�.� SySf - tkde/'
If the application is not made complete within thirty (30) days, it will be returned
to you and may he resubmitted when complete.
• This application has been assigned to /'t c %
(919/733-5083) of our Permits Unit for review and preps tioa of a draft permit.
Once the permit is drafted, public notice mugt be issued for forty-five (45) days
prior to final action on the issuance -or denial of the permi.t.' You will be advised
of any comments, recommendations, questions or other information necessary for the
review of the application.
I am, by copy of this letter, requesting that our Regional Office Supervisor
prepare a staff report and recommendations regarding this discharge. -If you have
any questions regarding this application, please contact the review person listed
above.
Sincerely yours,
Arthur Mouberry, P.E.
Supervisor, Permits and Engineering
cc: �✓,^ L
Regional Supervisor
An Equal Opportunity / Affirmative Action Employer

Ct H=457.5 V(zeel"mod
NORTH CAROLINA DEPT. OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT K A(C_
ENVIRONMENTAL MANAGEMENT COMMISSION
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
APPLICATION FOR PERMIT TO DISCHARGE - SHORT FORM D FOR
To be filed only by services, wholesale and retail trade,
and other commercial establishments including vessels
AGENCY
USE
Do not attempt to complete this form without reading the accompanying instructions
Please print or type
APPLICATION/��NUMBER
li
7
n
5
DATE RECEIVED
.�
K S
YEAR MO DAY
1, Name, address, and telephone number of facility producing discharge
A. Name ,TAIWF� /7®(rgg/2
B. Street address , z?-V Q/ &X
C. City a/d. L.0 D. State N
E. County 1z6rkj1UCt:z' •M F. ZIP 073_-_�-O
G. Telephone No. 9/!�j Z �0•z� :;g!q j
Area
Code
2. SIC
(Leave blank)
3. Number of employees 5-/NG-1-9J Ee/iJ l ij
4. Nature of business -s'�; � - -
5. (a) Check here if discharge occurs all year aw.or
(b) Check the month(s) discharge occurs:
1. o January 2. o February 3, ClMarch 4.(3 April 5, o May
6. ❑ June 7.O Ju.ly - B. o August 9. o September 10. o October
11. o November. 12. 0 December
(c) How many days per week:
1.01 2.0 2-3 3, 0 4-5 4.--6-7
6. Types of waste water discharged to surface waters only (check as applicable)
Flow, gallons per operating day
Volume treated before
discharging (percent)
Discharge per
operating day
0.1-999
1000-4999
5000-9999
10,000-
50,000
None
0.1-
30-
65-
95-
49,999
or more
29.9
64.9
94.9
100
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
A. Sanitary, daily
average
B._Cooling water, etc.,
daily average
C. Other discharge(s),
i
daily average;
Specify
D. Maximum per operat-
ing day for combined
discharge (all types)

1. If any t of the types of waste identified in item 6, either treated or un-
treated, are discharged to places other than surface waters, check below
as applicable.
Waste water is discharged to:
0.1-999
(1)
1000-4999
(2)
5000-9999
(3)
10,000-49,999
(4)
50,000 or more
(5)
A. Municipal sewvr• system
It. wl. l
C. Septic tank
D. Evaporation lagoon or pond
E. Other, specify:
B. Number of separate discharge points:
A. R-r B. ❑ 2-3 C, o 4-5 D. ❑ 6 or more
9. Name of receiving water or waters Jam,_,- �.'d� 114212.L ;� ,Z4 Te iVA/ 0_2r�
10. Does your discharge contain or -is it possible for your discharge to contain
one or more of the following substances IA!IgA as a result of your operations,
activities, or processes: ammonia, cyanide, aluminum, beryllium, cadmium,
chromium, copper, lead, mercury, nickel, selenium, zinc, phenols, oil and
grease, and chlorine (re Idua1).
A.❑yes B.o
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.
Printed Name of Person Signing
-,)VG—� ©/-`
Title
Da pplication SKgned
ig ture of Applicant
?North Carolina General Statute 143-215.6(b)(2) provides that: 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 Article 21 or regulations of the
Environmental Management Commission implementing that Article, or who falsifies, tampers with,
or knowly renders inaccurate any. recording or monitorigg device or method required to be
operated or maintained under Article 21.,07. regulations. -Of the Environmental Management Commissic
implementing that -,Article, s.hall'be.'•gut1ty:­Of' a misdemeanor punishable by a fine not to exceed
$10,000, or by imprisonment not to exceed six months, or by both. (18 U.S.C. Section 1001 provic
a punishment by a fine of"not more than $10,000 or imprisonment not more than 5 years, or both,
for a similar offense.)