NCG550361_Regional Office Historical File Pre 2018

;h
r;y
Water Resources
Environmental Quality
October 11, 2017
Mr. John Kluttz
2581 Essex Drive
Concord, NC 28025
SUBJECT: Compliance Evaluation Inspection
Wastewater Treatment System
NPDES Permit NCG550361
Cabarrus County, NC
Dear Mr. Kluttz
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
S. JAY ZIMMERMAN
Director
On October 5, 2017, Roberto Scheiler of this Office conducted a compliance inspection at the
subject residency. This inspection was conducted as a Compliance. Evaluation Inspection (CEI)
to insure compliance with permit requirements and conditions During the subject inspection, it
was noted that you requested a copy of your current permit. Enclosed is a copy of Technical
Bulletin for General Permit NCG550000 and a copy of your General Permit. At the time of
inspection treatment works appeared to be well maintained and operated. We wish to thank you
for your assistance regarding this inspection.
The enclosed report should be self-explanatory; however, should you have any questions, or
questions regarding this inspection, please do not hesitate to contact myself or Roberto Scheller
at [phone] or [e-mail].
Enclosed
cc: Wastewater Branch
Ele
Sincerely,
W. Corey Basinger, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ
"`Nathln j Compares ..
State of North Carolina I Environmental Quality
1611 Mail Service Center I Raleigh, North Carolina 27699-1611
919-707-9000

United States Environmental Protection Agency
Form Approved.
EPA Washington, D.C.20460
OMB No. 2040-0057
Water Compliance Inspection Report
Approval expires 8-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction Code NPDES yr/mo/day Inspection Type Inspector Fac Type
1 IN 1 2 15 1 3 I NCG550361 I11 12 17/10/05 17 18 i C i 19 i G i 20I
211111 1 1 I I I III I I I I I I I I I I I I I I I I I I I I I I I II I I I I I r6
I
Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 QA Reserved
67 70 i, i �1 � 72 i N � 73 i I- I74 751 III I I �80
LJ �I I I
Section B: Facility Data
Name and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
Entry Time/Date
Permit Effective Date
POTW name and NPDES permit Number)
04:00PM 17/10/05
13/08/01
2581 Essex Drive
2581 Essex Dr
Exit Time/Date
Permit Expiration Date
Concord NC 28025
04:25PM 17/10/05
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
Johnathan Kluttz,2581 Essex Dr Concord NC 28025/f704-791-7681/
•
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit Operations & Maintenance Records/Reports Self -Monitoring Program
Facility Site Review Effluent/Receiving Waters ,� Laboratory
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
Roberto Schaller MRO WQ//252-946-6481/
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
W. Corey Basinger MRO WQ//704-235-2194/
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
`� o
Page# 1

*A
NPDES
yr/mo/day
31 NCG550361 Ill 121 17/10/05 . 1 17
Inspection Type
18 ICI
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
Page# 2

or
I.
Permit: NCG550361 Owner- Facility: 2581 Essex Drive
Inspection Date: 10/05/2017 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?
Yes No NA NE
❑ ❑ ■ ❑
❑ ❑ ❑
■ ❑ ❑ ❑
■ ❑ ❑ ❑
■ ❑ ❑ ❑
Comment: Wastewater Treatment facilitv discharges into Cold Water Creek. Enclosed with this
.inspection is a copy of General Permit.
Effluent Pipe
Yes No NA NE
Is right of way to the outfall properly maintained?
M
❑
❑
❑
Are the receiving water free of foam other than trace amounts and other debris?
❑
❑
❑
If effluent (diffuser pipes are required) are they operating properly?
❑
❑,
❑
Comment: Effluent had very low discharge at time of inspection.
Effluent Samplinq
Is composite sampling flow proportional?
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)?
Yes No NA NE
❑ ❑ ■ ❑
* ❑ ❑ ❑
❑ ❑ ❑
❑ ❑ M ❑
❑ ❑ ❑
❑ M ❑ ❑
Comment: Samples are to be collected annually. Analysis of samples shall be preformed by
commercial laboratory. Annual wastewater analysis should include BOD, Total Suspended
Solids, Fecal Coliform, Total Residual Chlorine, and Flow (to be estimated).
Record Keeping
Yes No NA NE
Are records kept and maintained as required by the permit?
0
❑
❑
❑
Is all required information readily available, complete and current?
❑
0
❑
❑
Are all records maintained for 3 years (lab. reg. required 5 years)?
❑
❑
M
❑
Are analytical results consistent with data reported on DMRs?
❑
❑
M
❑
Is the chain -of -custody complete?
❑
❑
❑
Dates, times and location of sampling
Page# 3

Permit: NCG550361 Owner - Facility: 2581 Essex Drive
Inspection Date: 10/05/2017 Inspection Type: Compliance Evaluation
Record Keeping
Yes No NA NE
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?
❑
❑
M
❑
Has the facility submitted its annual compliance report to users and DWQ?
❑
❑
0
❑
(If the facility is = or > 5 MG permitted flow) Do they operate 24/7 with a certified operator
❑
❑
M
❑
on each shift?
Is the ORC visitation log available and current?
❑
❑
E
❑
Is the ORC certified at grade equal, to or higher than the facility classification?
❑
❑
M
❑
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?
❑
E
❑
❑
Facility has copy of previous year's Annual Report on file for review?
❑
❑
M
❑
Comment: Records for septic pump -out and effluent annual analysis should be avallable for review.
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?
0
❑
❑
❑
Is sand filter free of ponding?
0
❑
❑
❑
Is the sand filter effluent re -circulated at a valid ratio?
❑
❑
E
❑
# Is the sand filter surface free of algae or excessive vegetation?
0
❑
❑
❑
# Is the sand filter effluent re -circulated at a valid ratio? (Approximately 3 to 1)
❑
❑
M
❑
Comment: Recirculation Dumo not in use. If effluent parameters are exceeded recirculation pum
should be used to increase treatment efficiency.
Disinfection -Tablet Yes No NA NE
Are tablet chlorinators operational? 0 ❑ ❑ ❑
Are the tablets the proper size and type? 0 ❑ ❑ ❑
Number of tubes in use? 2
Is the level of chlorine residual acceptable? ❑ ❑ ❑
Is the contact chamber free of growth, or sludge buildup? ❑ ❑ ❑
Is there chlorine residual prior to de -chlorination? ❑ ❑ ❑
Comment:
i
Page# 4

M
f
Permit: NCG550361 Owner - Facility: 2581 Essex Drive
Inspection Date: 10/05/2017 Inspection Type: Compliance Evaluation
Disinfection -Tablet Yes No NA NE
Operations & Maintenance
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:
Yes No NA NE
❑ ❑ ❑
❑ ❑ ■ ❑
Page# 5

LEt
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
June 19, 2015
Mr. Johnathan Kluttz
2581 Essex Drive
Concord, NC 28025
Donald van der Vaart
Secretary
Subject: Compliance Evaluation Inspection
Single Family Residence Wastewater Treatment System
NPDES General Wastewater Permit No./Certificate of Coverage NCG550361
Dear Mr. Kluttz:
Enclosed please find a copy of the Compliance Evaluation Inspection Report for the
inspection conducted at your residence on May 7, 2015 by Ms. Barbara Sifford and Mr. Barry
Love of this office. Thank you for your assistance and cooperation during the inspection. The
system appeared to be operational and maintained.
A list of contact labs was provided to you for reference to contract the annual analytical data.
The web site is http://portal.ncdenr.or /t web/wq/lab/cert/certlablists. This is required to be
completed annually and available for review during the inspection. The results from the
sample you submitted on May 28, was received in this office on June 9 and indicates
compliance with the permit.
If you change the disinfection process you can submit the form I have included with this
report for the modification of the treatment process.
The report should be self-explanatory. If you have any questions, comments, or need
assistance with understanding any aspect of your permit or this report, please do not hesitate to
contact me at (704)-235-2196.
Cc: MSC-1617 Central Files
CEI- Report (BIMS)
NCG550000 General Permit
Sincerely,
�Ada,,4 (�;&d�
Barbara Sifford
Water Quality Regional Operations Section
Mooresville Regional Office-NCDENR
Mooresville Regional Office
610 East Center Avenue, Suite 301, Mooresville, North Carolina 28115
Phone: [phone] Fax: [phone]/Customer Service 1-877-623-6748
Internet: www,ncdenr.gov
An Equal Opportunity 1 Affirmative Action Employer — Made in part by recycled paper

United States Environmental Protection Agency
Form Approved.
EPA Washington, D.C. 20460
OMB No. 2040-0057
- -- --— --.- - -- --- - - I --
Water COmpH nce InspeCflOPI ep01t
Approval expires8-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction Code NPDES yr/mo/day Inspection Type Inspector Fac Type
1 IN I 2 15 I 3 I NCG550361 111 121 15/05/07 I17 18 I, I 19 I G I 20 I
21I
Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 QA ----------Reserved---------
I 72 L N j 731 I I74 751 I I I I I I I80
67 70Id I 71 ilI L
LJ � I I I 1
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)
08:OOAM 15/05/07
13/08/01
2581 Essex Drive
Exit Time/Date
Permit Expiration Date
2581 Essex Dr
09:30AM 15/05/07
18/07/31
Concord NC 28025
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
Other Facility Data
111
Name, Address of Responsible Official/Title/Phone and Fax Number
Contacted
Johnathan Kluttz,2581 Essex Dr Concord NC 28025//704-791-7681/
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
® Permit ® Operations & Maintenance ® Records/Reports ® Self -Monitoring Program
® Facility Site Review ® Effluent/Receiving Waters Laboratory
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
Barbara Sifford Division of Water Quality//704-663-1699
Barry F Love MRO WQ//704-663-1699 Ext.263/
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page#

I
NPDES yr/nno/day Inspection Type 1
31 NCG550361 I11 121 15/05/07 117 18 I C I
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
1. Annual analytical is listed on Page 3 of the permit this is to be done annually.
2.
Page#

a..
Permit: NCG550361 Owner -Facility: 2581 Essex Drive
Inspection Date: 05/07/2015 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?
Is the facility as described in the permit?
■
❑
❑
❑
Is the plant generally clean with acceptable housekeeping?
M
❑
❑
❑
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable
❑
M
❑
❑
Solids, pH, DO, Sludge Judge, and other that are applicable?
# Are there any special conditions for the permit?
❑
®
❑
❑
Comment: The system is operational and discharges to Cold Water Creek. Effluent is sampled
from
the chlorination tank rather than the discharge in the creek therefore the higher residual level
reported.
Is access to the plant site restricted to the general public?
N
❑
❑
❑
Is the inspector granted access to all areas for inspection?
■
❑
❑
❑
Comment: Permit renewed in 2013 for 5 Years. Annual fees have been paid.
Effluent Pipe
Yes No NA NE
Is right of way to the outfall properly maintained?
N ❑
❑
❑
Are the receiving water free of foam other than trace amounts and other debris?
0 ❑
❑
❑
If effluent (diffuser pipes are required) are they operating properly?
❑ ❑
M
❑
Comment: Creek has eroded some stream bank but pipe discharge is still in the flow of the stream.
This should.be checked to make sure pipe has not broken off.
Effluent Sampling
Yes No NA NE
Is composite sampling flow proportional?
❑
❑
M
❑
Is sample collected below all treatment units?
❑
❑
M
❑
Is proper volume collected?
❑
❑
M
❑
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: Annual analvtical is not beinq performed as required. List of commercial contract labs was
provided Results from the samping event was submitted to MRO on June 9, indicating the
facility is in compliance This is required annually to be reviewed on the next inspection.
Record Keeping Yes No NA NE
Are records kept and maintained as required by the permit? M ❑ ❑ ❑
Page# 3

Permit: NCG550361 Owner -Facility: 2581 Essex Drive
Inspection Date: 05/07/2015 Inspection Type: Compliance Evaluation
Record Keeping
Yes No NA NE
Is all required information readily available, complete and current?
M
❑
❑
❑
Are all records maintained for 3 years (lab. reg. required 5 years)?
❑
®
❑
❑
Are_ analytical results consistent with data reported on DMRs?
❑
❑
❑
Is the chain -of -custody complete?
0
❑
❑
❑
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?
❑
❑
M
❑
Has the facility submitted its annual compliance report to users and DWQ?
❑
❑
®
❑
(If the facility is = or > 5 MGD permitted flow) Do they operate 2417 with a certified operator
❑
❑
®
❑
on each shift?
Is the ORC visitation log available and current?
❑
❑
®
❑
Is the ORC certified at grade equal to or higher than the facility classification?
❑
❑
®
❑
Is the backup operator certified at one grade less or greater than the facility classification?
❑
❑
M
❑
Is a copy of the current NPDES permit available on site?
❑
M
❑
❑
Facility has copy of previous year's Annual Report on file for review?
❑
❑
®
❑
Comment: Copt/ of permit can be obtained from the web site under general permits for Single
Family
Residences, NCG550000.
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?
M
❑
❑
❑
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: There is a recirculation puma that is not beino used. If effluent Darameters are exceeded
this should be used to increase the treatment efficieny of the system.
Disinfection -Tablet Yes No NA NE
Are tablet chlorinators operational? ® ❑ ❑ ❑
Are the tablets the proper size and type? M ❑ ❑ ❑
Page# 4

Permit: NCG550361
Owner -Facility: 2561 Essex Drive
Inspection Date: 05/07/2015
Inspection Type: Compliance Evaluation
Disinfection -Tablet
Yes No NA NE
Number of tubes in use?
2
Is the.level of chlorine residual acceptable?
M
❑
❑
❑
Is the contact chamber free of growth, or sludge buildup?
0
❑
❑
❑
Is there chlorine residual prior to de -chlorination?
❑
❑
0
❑
Comment: De Chlorination is not required for this system.
Homeowner is investigating chaning to UV
instead of chlorine tablets. The application for General Permit is included with this
inspection report if the system is modified.
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: Alarms did not notify the owner of a pump failure earlier this year.
Yes No NA NE
❑ M ❑ ❑
❑ ❑ ❑
❑ ❑ ■ ❑
❑ M ❑ ❑
Page# 5

Jun.09.2015 07:10 AM 704-782-0218
7047820812
PAGE. 3/ 3
WSACC
4:�''�
I8014001:2004 # NC Star Public Sector
June 3, 2015
John Kluttz
2581 Essex Dr..
Concord, NC 28025
Subject: Kluttz Soptzc System Effluant Data
Attn: John Kluttz
WATER & SEWER AUTHORITY
OF CABARRUS COUNTY
Office: 232 Davidson Hwy.
Concord, NO 28027
Mail to: P.O. Box 428
Concord, NC 28026-0428
704.786,1783 4 704,795,1564 Fax
www.wsacc.org
Please find enclosed the analytical data for the Kluttz Sepkic
System sample collected 5/28/2015.
1f you have any questions or comments, please contact me at (704)
788-4164, ext. 116.
Sincerely,
C&
Cayc Atkinson
Labc atory Supervisor.
CA. BC
Enclosure

Jun.09.2015 07:10 AM 704-782-0818 704782081$ PAGE. 1/ 3
�a
WSACC
w�trtr�utir.
WATER Sr SEWER AUTHORITY OF CABARRUS COUNTY
CHAIN OF CUSTODY
LOCATION Kluttz Septic System CONTACT PERSON
SAMPLER 5-01u &ffr- PHONE;#
PIPE # > w l
John Kluttz
704-791,7631
% U�-I�l.dv� ��t ids � l �• �
n a ner
Sample
imseriptlon
Date
Time
Type (C,G)
preservation
(PIG)
Analysis Required
BOD
TSS
Effluent
%
Ca
None
P
Chlorine Residual
Effluent
G
Na2S20a
P
Fecal Coliform
Relinquished Cyl7itle
Date
Time
T mperature Upon Collection
(Print) ,�bj& ff V.7—
(Signature)
ReceivedRransportsd By:
Date
Time
Sample Integrity
(Print)
SE nature
Received In Lab By:
Date
Time
Temperature Upon Receipt
(Print)
Si nature
Comments:
Cv3��a�r jjJJVec�i�o� l�tt!"! �
C4 76 ch4 , . (?4-
""Verify that this is the: most recent revision.This is an t1M;0lg7'I•t01,JX,0 copy of a 0ONTROLl..ED Uocuniont. 5l2712015 11:03 AM'^'

Jun.09.2015 07:10 AM 704-782-0818 7047820818
KLUTTZ SEPTIC SYSTEM EFFLUENT
DATA REPORT
Kluttz Septic System Effluent
BOD <2,0 mg/L
TSS 10 mg/L
Chlorine Residual 0,500* mg/L
Fecal Coliform <1 co1,1100mL
Sample Collected 5/28/2015
"Chlorine Residual was not analyzed within 15 minute hold time. Result is not certified.
All samples were analyzed by WSACC Lab #177. e 0
PAGE. 2/ 3

r
Beverly Eaves Perdue
Governor
Mr. Johnathan Kluttz
2581 Essex Drive
Concord, NC 28025
Dear Mr. Kluttz:
X099W,
4-i�A
ate®
i�
NR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
February 5, 2010
Subject: Compliance Evaluation
NPDES Permit No. NCG550361
Cabarrus County
Dee Freeman
Secretary
Enclosed is a copy of the Compliance Evaluation Inspection (CEI) for the inspection conducted at the
subject facility on January 28, 2010, by Ms. Barbara Sifford with this Office. Thank you for your assistance
and cooperation during the inspection. The system appeared to be operational and maintained.
Analytical data for compliance monitoring for the treatment system has not been completed. The tank
has not been pumped at the frequency required by the permit. Details of the system are maintained in the file in
DWQ but the homeowner did not have a set of plans. The septic tank should be pumped at least every 5 years
to keep from overloading the sand filter bed.
The chlorine tablet dispenser needs to be cleaned out of old tablet material so that a new tablet can be
placed in the flow of the water. Chlorine tablets can be purchased from USA Blue Book on line or McCall
Brothers plumbing supply in Charlotte. A sample port needs to be made to collect a sample after contact time
with the chlorine prior to the discharge.
You can download a copy of the permit from our web site http://portal.ncdenr.orahveb/wq.
Enclosed with this letter is the Notice of Intent form to submit for renewing your permit and changing
the owner name. Include the fees with this form and send to Raleigh.
Please submit a copy of the analysis, and documentation that the septic tank has been pumped to this
office within 90 days to complete your files.
Mooresville Regional Office
Location: 610 East Center Ave., Suite 301 Mooresville, NC 28115
Phone: [phone] Fax: [phone] Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
An Equal Opportunity 1 Affirmative Action Employer — 50% Recycled/10% Post Consumer paper
One
.
NorthCarolina
�'Vdtl>fl�l���

11
The enclosed reports should be self-explanatory. If you have any questions, comments, or need
assistance with understanding any aspect of your permit or this report, please do not hesitate to contact me at
[phone],ext 2196.
Sincerely,
7
Barbara Safford
Technical Consultant
Enclosure —Inspection report
Notice of Intent Form
Lab lists (sent previously)
Chlorine tablet information (sent previously)

F
United States Environmental Protection Agency
Form Approved.
E P n�1 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 15I 31 NCG550361 111 121 10/01/28' ' 117 18I CI 191 SI 20III
Remarks
211 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Ll I I I 1 1'
Inspection Work Days Facility Self -Monitoring Evaluation Rating 81 QA - --- —------ ---Reserved----------
67I 2.0 169 701 31 711 I 721 NJ 73I � 174 751 I I I I _I I 180
W
Section B: Facility Data
Name and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
Entry Time/Date
Permit Effective Date
POTW name and NPDES permit Number)
10:00 AM 10/01/28
93/11/01
2581 Essex Drive
Exit Time/Date
Permit Expiration Date
2581 Essex Dr
Concord NC 28025
11:00 AM 10/01/28
97/07/31
Name(s) of Onsite Representative(s)fTitles(s)/Phone and Fax Number(s)
Other Facility Data
Name, Address of Responsible Official/Title/Phone and Fax Number
Contacted
Julius Swetenburg,2581 Essex Dr Concord NC 28025//704-788-6575/ No '
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit Operations & Maintenance Records/Reports Self -Monitoring Program
Sludge Handling Disposal Facility Site Review Effluent/Receiving Waters Laboratory
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
Barbara Sifford MRO WQ//704-663-1699 Ext.2196/
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page # 1

NPDES yr/mo/day Inspection Type (cont.) 1
3I NCG550361 I11 12I 10/01/28 1
17 18Icl
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
Permit expired in 1997 under the owner name of Swetenburg. The residence has been sold twice since
then, current owner (Johnathan Kluttz) purchased residence in 2003 according to cabarrus county tax
records. Enclosed with this report is NOI to reissue the permit with new owners name. System is
completely functional but has not had any analysis performed and septic tank has not been pumped and
homeowner is using pool chlorine. Completing these items should have the system in compliance. Please
forward a copy of the analysis for State records indicating that the system is discharging wastewater that
meets the compliance monitoring parameters.
Page # 2

F
Permit: NCG550361
Inspection Date: 01/28/2010
Owner -Facility: 2581 Essex Drive
Inspection Type: Compliance Evaluation
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: The system is operational and discharging into Cold Water Creek. A
sampling location needs to be accessible on the discharge of the system.
Permit Yes No NA NE
(If the present permit expires in 6 months or less). Has the permittee submitted a new application? ❑ ■ n n
Is the facility as described in the permit? ■ n n 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 In n
Comment: Two conditions for the system are to pump the tank every 3-5 years and
have annual analysis performed for compliance of the system. A list of commercial labs
has been provided to the home owner. The permit expired in 1997 under the previous
owners name. A permit application needs to be submitted and fee paid to reissue the
permit in the current owners name.
Septic Tank
Yes
no
NA N
(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: Second septic tank is pump tank to the sand bed.
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
n
■
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
Comment: Sand filter bed is free of vegetation.
Disinfection -Tablet
Yes
No
NA
NE
Are tablet chlorinators operational?
■
n
n
n
Page # 3

Permit: NCG550361 Owner -Facility: 2581 Essex Drive
Inspection Date: 01/28/2010 Inspection Type: Compliance Evaluation
Yes No NA NE
Disinfection -Tablet
Are the tablets the proper size and type? fl ■ ❑
2
Number of tubes in use?
Is the level of chlorine residual acceptable? ❑ ❑ ❑ ■
Is the contact chamber free of growth, or sludge buildup? ■ ❑ ❑ ❑
Is there chlorine residual prior to de -chlorination? ■ D ❑ Cl
Comment: System is not required to de -chlorinate. Their is an 800 gallon contact
chamber after chlorination with air that would disipate the chlorine prior to discharge.
Pool tablets are not approved to be used to disinfect wastewater, information has been
provided for proper tablets.
Page # 4

F
&74
NCDENR
N--r" Car+cUw L�M✓_- of
F ,rn.M.F.NT .40 Naw-..u. F2�9Q::xF�
Division of Water Quality / Water Quality Section
National Pollutant Discharge Elimination System
NOTICE OF INTENT - NCG550000
FOR AGENCY USE ONLY
Date Received
Year Month Day
Certificate of Coverage
NCG
Check # Amount
Perarit Assigned to
National Pollutant Discharge Elimination System application for coverage under General Permit
NCG550000: Single Family Domestic Units and/or facilities discharging less than 1000 gallons per
day of domestic wastewater and similar point source discharges
(Please print or type)
1) Region contact (Please note: This application will be returned if you have not met with a
representative from the appropriate regional office):
Please list the NCDENR Regional Office representative(s) with whom you have met:
Name: Date:
2) Mailing address of owner/operator:
Owner Name
Street Address
City State ZIP Code
Telephone No. (Home) ( ) (Work) ( )
" Address to which all permit correspondence will be mailed
3) Location of facility producing discharge:
Street Address
City State ZIP Code
County
Telephone No. ( )
4) Physical location information:
Please provide a narrative description of how to get to the facility (use street names, state road
numbers, and distance and direction from a roadway intersection).
5) This NPDES permit application applies to which of the following:
❑ New or Proposed. (system not yet constructed)
❑ Existing (system fully constructed); If previously permitted by local or county health department,
please provide the permit number and issue date
❑ Modification (existing system with proposed changes); please describe the nature of the
modification:
6) Description of Discharge:
a) Amount of wastewater to be discharged:
Number of bedrooms x 120 gallons per bedroom = gallons per day to be permitted.
Page 1 of 3 07/07

NCG550000 N.O.I.
b) Type of facility producing waste (please check one):
❑ Primary residence ❑ Vacation/second home
❑ Other:
7) Please check the components that comprise the wastewater treatment system:
❑ Septic tank ❑ Dosing tank ❑ Recirculating sand filter(s)
❑ Primary sand filter ❑ Secondary sand filter ❑ Other form of disinfection
❑ Chlorination ❑ Dechlorination ❑ Post Aeration (specify type)
8) Receiving waters:
a) What is the name of the body or bodies of water (creek, stream, river, lake, etc.) that the facility
wastewater discharges end up in?
b) Stream Classification (if known):
9) Application Requirements:
Applications for new/proposed facilities (unbuilt) should include the following:
❑ An original letter and two (2) copies requesting a general permit and Authorization to Construct (ATC).
❑ A signed and completed original and two copies of this Notice of Intent application.
❑ A check or money order for the permit fee of $60.00 made payable to NCDENR.
❑ Letter from the county health department evaluating the proposed site for, all types of ground
absorption and innovative non -discharge systems. Document the repair potential of the failed system.
❑ An evaluation of the possibility of connecting to a regional sewer system (approximate distance & cost
to connect).
❑ A 7Q10 flow estimate at the proposed wastewater discharge point from the US Geological Survey
(919- 571-4000)
❑ Three sets of plans and specifications of proposed treatment system. Please note that a Professional
Engineer (P.E.) will be required to certify all new systems.
❑ The following setbacks must be met for all new facilities (15A NCAC 02T .0506(b)).
o Any private or public water supply source - 100 ft
o Surface Waters - 50 ft
o Any habitable residence under separate ownership or not to be maintained as part of
project site - 100 ft
o Any property line - 50 ft
o Any well with exception of monitoring wells - 100 ft
Applications for existing (permitted or unpermitted) facilities requiring modifications should
include the followina:
❑ An original letter and two (2) copies requesting a general permit (if the system is unpermitted)
and/or an Authorization to Construct (ATC).
❑ A signed and completed original and two copies of this Notice of Intent Application.
❑ A check or money order for the permit fee of $60.00 made payable.to NCDENR (not required for
currently permitted systems).
❑ Three sets of plans and specifications of the proposed treatment system. Please note that a
Professional Engineer (P.E.) will be required to certify all modifications other than the addition of
chlorination/dechlorination.
❑ Invoice showing the septic tank has been pumped and serviced within the last 12 months (only
when existing septic tank will be used)
Page 2 of 3 7/07

NCG550000 N.O.I.
Applications for existing (unpermitted) facilities with no proposed modifications should include
the following:
❑ An original letter and two (2) copies requesting a general permit.
❑ A signed and completed original and two copies of this Notice of Intent Application.
❑ A check or money order for the permit fee of $60.00 made payable to NCDENR.
❑ Invoice showing the septic tank has been pumped and serviced within the last 12 months
10) Additional Application Requirements:
a) If a consulting engineer is submitting this application:
❑ Please include documentation from the applicant showing that the engineer (or firm) has been
designated an authorized representative of the applicant.
❑ Final plans for the treatment system must be signed and sealed by a North Carolina registered
Professional Engineer and stamped -."Final Design - Not released for construction".
❑ Final specifications for all major treatment components must be signed and sealed by a North
Carolina registered Professional Engineer and shall include a narrative description of the
treatment system to be constructed.
11) Certification:
I certify that I am familiar with the information contained in this application and that to the best of my
knowledge and belief such information is true, complete, and accurate.
Printed Name of Person Signing:
Title:
(Signature of Applicant) (Date Signed)
North Carolina General Statute 143-215.6 b (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any
application, record, report, plan or other document filed or required to be maintained under Article 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
required to be operated or maintained under Article 21 or regulations of the Environmental
Management Commission implementing that Article, shall be guilty of a misdemeanor punishable by a
fine not to exceed $25,000, or by imprisonment not to exceed six 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.)
Mail package to:
NPDES Permitting Program
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Phone: [phone]
The submission of this document does not guarantee the issuance of an NPDES permit
Page 3 of 3 7/07

F
Start
End Tim
SINGLE FAMILY WASTEWATER SYSTEM CHECKLIST
1012812014
Permittee: To r K Permit:
Address: E-mail-
Phone: f :' W) 2ct_-_ 7 (`� I `4E—Cell Phone:( - County:
The Permittee is responsible for the operation and maintenance of the entire wastewater treatment and dicnnca1 cvcram
Doesn't
Did Not
Yes. No
Apply
Investigate
1. Is the current resident in the home the Permittee?
2. If not does the resident rent from the permittee?
❑ ❑
9--
❑
3. Change of Ownership form needed? (mail the form with the inspection letter)
❑ 0�
❑
❑
4. Is there a inspection and maintenance agreement with a contractor?
❑ 2/
❑
❑
5. If yes to #4 who is the contractor?
SEPTIC TANK The septic tank and filters should be checked annually and pumped/cleaned as needed.
6. Is all wastewater from the home connected to the septic tank?
❑
El
❑ .
7. Does the permittee/resident know where the septic tank is located?
❑
❑
❑
8. Has the septic tank been pumped in the last 5 years?
❑
❑
❑
9. If yes to #8 date, if known If proof, describe
106. es the septic tank have an EFFLUENT FILTER or SANITARY T? (circle
one)
es to filter when was the filter cleaned? By who?
-FILTE / TREATili1ENT PODS YES NO
If no proceed to the next section.
ble sand filter surfaces shall be raked and leveled every six months and any vegetative growth
shall be removed manually.
12. Is system something other than a sand filter?
❑ E7'
❑
❑
13. If yes, what kind? (examples - Peat, Textile or brand name - Advantex, etc.)
14. Does the permittee know where the filter is?
❑
❑
❑
15. If above ground does the filter require maintenance?
Er ❑
❑
❑
If maintenace is required explain in the comment section. J
DISINFECTION / UV YES NO
If no proceed to the next section.
The ultraviolet unit shall be checked weekly. The lamps and sleeves should be cleaned or replaced as
needed to ensure proper disinfection.
16. Is UV working?
❑ ❑
❑
❑
17. Has the UV Unit been serviced and bulbs cleaned?
❑ ❑
❑
❑
18. Who completes the weekly check for the UV?( Non -Discharge)
DISINFECTION / TABLETS YES NO
Ig no proceed to the next section.
The tablet chlorinator unit shall be checked weekly to ensure continuous and proper operation.
19. Does the permittee have the correct chlorine tablets?(If none, mark No)
❑
❑
0
22. Does the Permittee know the location of the chlorinator?
-❑
❑ _
❑
23. Were chlorine tablets observed in the chlorinator?
❑
❑
❑
24. Are tablets contacting water? If possible poke them to determine. H o �o
�� }❑23.
❑
❑
DECHLOR.(Discharge only) YES NO
if no proceed to the next section.
The dechlorinator unit shall be checked weekly to ensure continuous and proper operation.
25. Does the permittee know where the dechlor is?
❑ ❑
❑
❑
26. Does the permittee have the correct dechlor tablets?
❑ ❑
❑
❑
27. Were dechlor tablets observed in the dechlorination chamber?
❑ ❑
0
❑

DRIFT Doesn't
Yes No Aonly
28. Are tablets contacting water? If possible poke them to determine.
PUMP TANK YES NO
If no proceed to the next section.
All pump and alarm sytems shall be inspected monthly. (non -discharge)
29. Is the pump working?
Ir l ❑
❑
❑
30. Is the audible and visual high water alarm operational?
❑ ❑
❑
2
31. Did the permittee know how to check the pump & high water alarm?
u
❑
❑
32. Last functional test?
DISCHARGE ONLY YES NO
If no proceed to the next section.
A visual review of the outfall location shall be executed twice each year (one at the time of sampling to ensure no visa solids or evidence of a malfunction.
33. Does the permittee know where the outfall is?
❑
❑
❑
34. Were you able to locate the outfall?
u ❑
❑
35. Is the end of the discharge pipe visible? If not, explain why.
2 ❑
� ❑
❑
36. Is outlet discharging? jr,,
,
❑
❑
37. Is right of way maintained around the discharge point?
❑
❑
❑
38. Any Lab Results available? LVI 51110 --n­... 4 � o � �
❑
❑
❑
39. Is there evidence of solids around the discharge point?
[a ❑
❑
❑
DRIP or SPRAY YES NO
If no proceed to the next section.
The irrigation sysetm shall be inspected monthly to ensure the system is free of leaks and equipment is operating as designed.
40. Is the system DRIP or IRRIGATION (circle one)? If irrigation number of sprinkler heads.
41. Are the buffers adequate?
❑ ❑
❑
❑
42. Is the site free of ponding and runoff?
❑ ❑
❑
❑
43. Does the application equipment appear to be working properly?
❑ ❑
❑
❑
44. Is there a two wire fence?
❑ ❑
❑
❑
GENERAL
45. Are the treatment units locked and or secured? N J- i-- k-J `�'
❑ El'
El❑
Cvve—V,_S
�
a-
❑
❑
37. Has resident had any sewage problems? If yes explain in UA Comment section.
37. Is the system compliant?
38. Is the system failing? If yes, take pictures if possible.
❑
❑
❑
39. If system is failing, any sign of children or animals contacting sewage?
❑ E�
❑
❑
Comments: Photos Taken?
YES
NO

b
Beverly Eaves Perdue
Governor
Mr. Johnathan Kluttz
2581 Essex Drive
Concord, NC 28025
Dear Mr. Kluttz:
� E%
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins Dee Freeman
Director Secretary
January 20, 2010
Subject: Single Family Residence
NPDES General Wastewater Permit
Certificate of Coverage NCG550361
Compliance Evaluation Inspection
The Division of Water Quality (DWQ) data base records show that you currently own/operate a single family
residence (SFR) wastewater treatment and disposal, system. DWQ personnel from the Mooresville Regional Office (MRO)
need to conduct a compliance evaluation of your system in order to verify that your system is operating properly. This review
should take approximately one hour.
Due to the difficulties of contacting you by phone during the workday we are requesting that you contact this office
to pre -schedule this visit. Please contact me at 704-663-1699, during the weekday to schedule this inspection. Please leave
your name and a day time phone number and I will return your call as soon as possible.
Below is a listing of the items that are required by the permit and will be reviewed during the inspection:
Certificate of Coverage: Letter issued by DWQ upon renewal of the permit.
Schematic of the Treatment System Units
Analytical Monitoring: Required annually, listed in permit.
Septic Tank Inspections/Pumping: septic tank pumping and cleaning
Chlorination Tablets: Type of tablets .
Please contact this office as soon as possible to set up a schedule that is convenient to you:
Sincerely,
Barbara Sifford
Technical Consultant
Mooresville Regional Office
Mooresville Regional Office
Location: 610 East Center Ave., Suite 301 Mooresville, NC 28115
Phone: [phone] Fax: [phone] Customer Service: 1-877-623-6748
Internet: wNw.ncwaterquality.org
An Equal opportunity 1 Affirmative Action Employer— 50% Recycled!10% Post Consumer paper
One
NorthCarolina
atlmald'l� f .

LTTWA
NCDENR
C4-vrrn C � Cem.rwevr
FNvI mw..IK Qm N4URN. RI94:K/9
Division of Water Quality / Water Quality Section
National Pollutant Discharge Elimination System
NOTICE OF INTENT - NCG550000
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
Certificate ofCovera e
N
Check X
Amount
Permit Assigned to
National Pollutant Discharge Elimination System application for coverage under General Permit
NCG560000: Single Family Domestic Units and/or facilities discharging less than 1000 gallons per
day of domestic wastewater and similar point source discharges
(Please print or type)
1) Region contact (Please note: This application will be returned if you have not met with a
representative from the appropriate regional office):
Please list the NCDENR RegionalOfficerepresentative(s) with whom you have met:
Name: 'd Date:. / f o�g �261y
2) Mailing address of owner/operator:
Owner Name _-mooAnatbaa ndf z
Street Address e9S91 Esy r lliv e
City `4hf6r44 State ZIP Code
Telephone No. (Home) (7� /P 1 �� (Work) (7by) 74/'7&t1
" Address to which all permit correspondence will be mailed
3) Location of facility producing discharge:
Street Address
City State ZIP Code g0
County Cabarrus
Telephone No. (76q ) 721 _1?q&D
4) Physical location information:
Please provide a narrative description of how to get to the facility (use street names, state road
numbers, and distance and direction from a roadway intersection).
5) This NPDES permit application applies to which of the following:
❑ New or Proposed (system not yet constructed)
Existing (system fully constructed); If previously permitted by local or county health department,
please provide the permit number /� f�� SS'6 3(� and issue date
❑ Modification (existing system with proposed changes); please describe the nature of the
modification:
6) Description of Discharge:
a) Amount of wastewater to be discharged:
Number of bedrooms x 120 gallons per bedroom = yl� gallons per day to be permitted.
Page 1 of 3 07/07

NCG550000 N.O.I.
b) Type of facility producing waste (please check one):
tzr Primary residence ❑ Vacation/second home
❑ Other:
7) Please check the components that comprise the wastewater treatment system:
VSSeptic tank
RIP"rimary sand filter
Chlorination
8) Receiving waters:
❑ Dosing tank ❑ Recirculating sand filter(s)
❑ Secondary sand filter ❑ Other form of disinfection
❑ Dechlorination ❑ Post Aeration (specify type)
a) What is the name of the body or bodies of water (creek, stream, river, lake, etc.) that the facility
wastewater discharges end up in? P
b) Stream Classification (if known):
9) Application Requirements:
Applications for new/proposed facilities (unbuilt) should include the following:
❑ An original letter and two (2) copies requesting a general permit and Authorization to Construct (ATC).
❑ A signed and completed original and two copies of this Notice of Intent application.
❑ A check or money order for the permit fee of $60.00 made payable to NCDENR.
❑ Letter from the county health department evaluating the proposed site for all types of ground
absorption and innovative non -discharge systems. Document the repair potential of the failed system.
❑ An evaluation of the possibility of connecting to a regional sewer system (approximate distance & cost
to connect).
❑ A 7Q10 flow estimate at the proposed wastewater discharge point from the US Geological Survey
(919- 571-4000)
❑ Three sets of plans and specifications of proposed treatment system. Please note that a Professional
Engineer (P.E.) will be required to certify all new systems.
❑ The following setbacks must be met for all new facilities (15A NCAC 02T .0506(b)).
o Any private or public water supply source - 100 ft
o Surface Waters - 50 ft
o Any habitable residence under separate ownership or not to be maintained as part of
project site - 100 ft
o Any property line - 50 ft
o Any well with exception of monitoring wells - 100 ft
Applications for existing (permitted or unpermitted) facilities requiring modifications should
include the following:
❑ An original letter and two (2) copies requesting a general permit (if the system is unpermitted)
and/or an Authorization to Construct (ATC). .
❑ A signed and completed original and two copies of this Notice of Intent Application.
❑ A check or money order for the permit fee of $60.00 made payable to NCDENR (not required for
currently permitted systems).
❑ Three sets of plans and specifications of the proposed treatment system. Please note that a
Professional Engineer (P.E.) will be required to certify all modifications other than the addition of
chlorination/dechlorination.
&rnvoice showing the septic tank has been pumped and serviced within the last 12 months (only
when existing septic tank will be used)
Page 2 of 3 7/07

r
NCG550000 N.O.I.
Applications for existing (unpermitted) facilities with no proposed modifications should include
the following:
❑ An, original letter and two (2) copies requesting a general permit.
❑ A signed and completed original and two copies of this Notice of Intent Application.
❑ A check or money order for the permit fee of $60.00 made payable to NCDENR.
❑ Invoice showing the septic tank has been pumped and serviced within the last 12 months
10) Additional Application Requirements:
a) If a consulting engineer is submitting this application:
❑ Please include documentation from the applicant showing that the engineer (or firm) has been
designated an authorized representative of the applicant.
❑ Final plans for the treatment system must be signed and sealed by a North Carolina registered
Professional Engineer and stamped - "Final Design - Not released for construction".
❑ Final specifications for all major treatment components must be signed and sealed by a North
Carolina registered Professional Engineer and shall include a narrative description of the
treatment system to be constructed.
11) Certification:
I certify that I am familiar with the information contained in this application and that to the best of my
knowledge and belief such information is true, complete, and accurate.
Printed Name of Person Signing: �1�11n a?Qi1 7�
Title: I i,*-
21to
(Signature of Applicant) (Date Signed)
North Carolina General Statute 143-215.6 b (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any
application, record, report, plan or other document filed or required to be maintained under Article 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
required to be operated or maintained under Article 21 or regulations of the. Environmental
Management Commission implementing that Article, shall be guilty of a misdemeanor punishable by a
fine not to exceed $25,000, or by imprisonment not to exceed six 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.)
Mail package to:
NPDES Permitting Program
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Phone: [phone]
The submission of this document does not guarantee the issuance of an NPDES permit
Page 3 of 3 7/07

KLUT fZ SEPTIC S-N,"' TEM -tUFLUENT
Sa.vup!,--NowU,r CoRmBate Test units
.07
BoUl
02 Revidue, 4.1
fecal C.bll; NO in
TSS
Wedhm�ayFap J of I

TATEMENT
DATE
TERMS
10'
F.
ADDRESS
IN ACCOUNT WITH
DC5812

KLUTTZ SEPTIC SYSTEM EFFLUENT
SampleNumber CollectDate Test Result Units
43209 4/15/2010
BOD 2.3 mg/L
C12 Residual 35 ug/L
Fecal Coliform <1 CON 00 ml
TSS <2.5 mg/L
Wednesday, April 21, 2010 Page 1 of I

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality -
Beverly Eaves Perdue, Governor Coleen H. Sullins, Director Dee Freeman,,,Seeretary
` June 18; 2010'
JUN 2 $ 2010
Johnathan Kluttz
2581 Essex Drive
Concord, NC 28025
Subject: Renewal of coverage / General Petm-it NCG550000
2581 Essex Drive
Certificate of Coverage NCG550361
Cabarrus County
Dear Permittee:
In accordance with your renewal application [received on June 17, 20101, the Division is renewing
Certificate of Coverage (CoC) NCG550361 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 October 15, 2007 [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 reissuance of the certificate of coverage.
Contact the Mooresville 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 Act or 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 Charles
Weaver of the NPDES staff [919 807-6391 or [e-mail]].
Sincerely,
for Coleen H. Sullins
cc: Central Files _
Jlooresville i—Re gional Office_ 1 Surface Water Protection
NPDES file
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 One '512 North Salisbury Street, Raleigh, North Carolina 27604 NOfthCarolina
Phone: [phone] / FAX [phone] / Internet: www.ncwaterquality.org
;Vatut ally
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
GENERAL PERMIT NCG550000
CERTIFICATE. OF COVERAGE NCG550361
_ r
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,
Johnathan Kluttz
is hereby authorized to discharge domestic wastewater [480 GPD] from a facility located at
2581 Essex Drive
Concord
Cabarrus County
to receiving waters designated as Little Cold Water Creek, a class C stream in subbasin 03-07-12
of the Yadkin -Pee Dee 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 June 18, 2010.
This Certificate of Coverage shall expire on July 31, 2012.
Signed this day June 18, 2010
f r Moleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission

0
March 20, 2010
NPDES Permitting Program
Division of Water Quality
1617 Mail Service Center
Raleigh, NC 27699-1617
RE: Permit #NCG550361
To Whom It May Concern:
I am requesting Permit Number NCG550361 be updated and transferred into my name.
Enclosed are the completed Notice of Intent Form, a check in the amount of $60 for the permit fee and
documentation that the septic tank was pumped on 2/10/2010 as well as the water analysis that was
requested by Barbara Sifford of your agency.
Please contact me if -additional information is needed.
Thank you,
Johnathan L. Kluttz
Homeowner
2581 Essex Drive, Concord NC 28025
JUN 1 7 2010
QENR .. "�fl�A u

ArA011AV
NCDENR
���a�
FNVmmmr*M-w rr vw Hamm. ---Cr9
Division of Water Quality / Water Quality Section
National Pollutant Discharge Elimination System
NOTICE OF INTENT - NCG550000
National Pollutant Discharge Elimination System application for coverage 1
NCG550000: Single Family Domestic Units and/or facilities discharging less
day of domestic wastewater and similar point source disch
(Please print or type)
1) Region contact (Please note: This application will be returned if you have
representative from the appropriate regional office):
in
I CertifcateofCoveraee I
JUN 1 7 2010
Please list the NCDENR Regional Office representative(s) with whom you have met: _
Name: �Glrp ira 'S'IF�ard Date: / f X !o 1-2616
2) Mailing address of owner/operator,:
Owner Name Tdhna l /. Ilan k hd e—'
Street Address
City C'ahcUrQ State A)C ZIP Code 2130� S
Telephone No. (Home) (7� �C 3� (Work) (76q 74i'7�1�/
" Address to which all permit correspondence will be mailed
3) Location of facility producing discharge:
Street Address '�2 S$/ IE�IsPY Dr, ue
City State ZIP Code geogj
County CabArru S
Telephone No. (76q ) 79, —9��
4) Physical location information:
Please provide a narrative description of how to get to the facility (use street names, state road
numbers, and distance and direction from a roadway intersection).
5) This NPDES permit application applies to which of the
❑ New orProposed (system not yet constructed)
0 Existing (system fully constructed); If previously permitted by local or county health department,
please provide the permit number /�/�(� SS6 3f/O and issue date
❑ Modification (existing system with proposed changes); please describe the nature of the
modification:
6) Description of Discharge:
a) Amount of wastewater to be discharged:
Number of bedrooms x 120 gallons per bedroom = LIA
yid gallons per day to be permitted.
Page 1 of 3 07/07

FIrNCG660000 N.O.I.
b) .Type of facility producing waste (please check one):
Primary residence ❑ Vacation/second home
❑ Other:
7) Please check the components that comprise the wastewater treatment system:
VSeptic tank ❑ Dosing tank ❑ Recirculating sand filter(s)
121101'rimary sand filter ❑ Secondary sand filter ❑ Other form of disinfection
chlorination ❑ Dechlorination ❑ Post Aeration (specify type)
8) Receiving waters:
a) What is the name of the body or bodies of water (creek, stream, river, lake, etc.) that the facility
wastewater discharges end up in?
b) Stream Classification (if known):
9) Application Requirements:
Applications for new/proposed facilities (unbuilt) should include the following:
❑ An original letter and two (2) copies requesting a general permit and Authorization to Construct (ATC).
❑ A signed and completed original and two copies of this Notice of Intent application.
❑ A check or money order for the permit fee of $60.00 made payable to NCDENR.
❑ Letter from the county health department evaluating the proposed site for all types of ground
absorption and innovative non -discharge systems. Document the repair potential of the failed system.
❑ An evaluation of the possibility of connecting to a regional sewer system (approximate distance & cost
to connect).
❑,A 7Q10 flow estimate at the proposed wastewater discharge point from the US Geological Survey
(919- 571-4000)
❑ Three sets of plans and specifications of proposed treatment system. Please note that a Professional
Engineer (P.E.) will be required to certify all new systems.
❑ The following setbacks must be met for all new facilities (15A NCAC 02T .0506(b)).
o Any private or public water supply source - 100 ft
o Surface Waters - 50 ft
o Any habitable residence under separate ownership or not to be maintained as part of
project site - 100 ft
o Any property line - 50 ft
o Any well with exception of monitoring wells - 100 ft'
Applications for existing (permitted or unpermitted) facilities requiring modifications should
include the following.
❑ An original letter and two (2) copies requesting a general permit (if the system is unpermitted)
and/or an Authorization to Construct (ATC).
❑ A signed and completed original and two copies of this Notice of Intent Application.
❑ A check or money order for the permit fee of $60.00 made payable to NCDENR (not required for
currently permitted systems).
❑ Three sets of plans and specifications of the proposed treatment system. Please note that a
Professional Engineer (P.E.) will be required to certify all modifications other than the addition of
chlorination/dechlorination.
voice showing the septic tank has been pumped and serviced within the last 12 months (only
when existing septic tank will be used)
Page 2 of 3 7/07

PV
NCG660000 N.O.I.
Applications for existing (unpermitted) facilities with no proposed modifications should include
the following:
❑ An original letter and two (2) copies requesting a general permit.
❑ A signed and completed original and two copies of this Notice of Intent Application.
❑ A check or money order for the permit fee of $60.00 made payable to NCDENR.
❑ Invoice showing the septic tank has been pumped and serviced within the last 12 months
10) Additional Application Requirements:
a) If a consulting engineer is submitting this application:
❑ Please include documentation from the applicant showing that the engineer (or firm) has been
designated an authorized representative of the applicant.
❑ Final plans for the treatment system must be signed and sealed by a North Carolina registered
Professional Engineer and stamped "Final Design - Not released for construction".
❑ Final specifications for all major treatment components must be signed and sealed by a North
Carolina registered Professional Engineer and shall include a narrative description of the
treatment system to be constructed.
11) Certification:
certify that I am familiar with the information contained in this application and that to the best of my
knowledge and belief such information is true, complete, and accurate.
Printed Name of Person Signing: �1Qbn afilla nZ
Title: /iGrfil eI-*-
(Signature of Applicant) (Date Signed)
North Carolina General Statute 143-216.6 b (i) provides that:
Any person who, knowingly makes any false statement, representation, or certification in any
application, record, report, plan or other document filed or required to be maintained under Article 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
required to be operated or maintained under Article 21 or regulations of the Environmental
Management Commission implementing that Article, shall be guilty of a misdemeanor punishable by a
fine not to exceed $25,000, or by imprisonment not to exceed six 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.)
Mail package to:
NPDES Permitting Program
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Phone: [phone]
The submission of this document does not guarantee the issuance of an NPDES permit
Page 3 of 3 7/07

lk
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KLUTTZ SEPTIC SYSTEM EFFLUENT
Salup!tTlarAcy'. callintuate Tost Result units
Mm' P-PA-77-7---
443209
Decal coliform 1 rill CID M)
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I

CLaRIS - Print
Page 1 of 1
-i& ffi3sCi tffi
Tho Eenlca of AmltaR Riotampmts
---NORTH CAROLINA
Print This Card
Cabarr is County shall not be held liable for any errors in the data represented on this map. This
includes errors of omission, commission, concerning the content of the data, and relative
positional accuracy of the data. The data cannot be construed to be a legal document. Primary
sources from which this data was compiled must be consulted for verification of information
represented on this map document.
Date Printed 1/11/2010 4:28:04 PM
NAP ►AACEL LOT EI[E OA AOREAOE
Zoe" l
26B 30 AUM x I Srr.
TWF. #11
•g5Pc
NEW ORRAIRION '
'/o LOT #30 ENGLISH WOODS
C= WATER EIRZ DIST.
O>'IN[R7 NAY[
STAMPS
OAT[
ACQUIRED
tKitD
ROOK
t S B. & M ILY N.
8/10179
510
2. EB
3, ,MITE, MYDE LUTEPR & WM
d291
4, ANy(KkM IED
5-27-94
1251t
4-2-96
1601
6. IMENTZ, JCH71iTEM L. AND WIFE An F.
6 03 03
7.
e.
9,
1Q
11.
I7.
Township
111
Pin 156402368320000
Map
1026
Old Pin 156402357660000
Submap
16
City
Parcel
10030
Fire District
Suffix
100
Plat Book
Real ID 111-026B-0030.00
Plat Page
Property Description
P/O LOT 30 ENGLISI-i WOODS
Lot Size/Acreage
Comments
Transaction Details
Type Current Owner I % Stamps Hate Book Page
h' KLUTTZ JOHNATHAN L & KLUTTZ AMY F/WIFE 0.0000 0.0000 1 06/03/2003 04580 036
http://www.co.cabarrus.ne.us/ClarisPC/Print.aspx 1/11/2010

uj
6, -

Page 1 of 2
Internet t +c ur ty 201
Trip to 2681 Essex Dr
Concord, NC 28025-9090
27.71 miles -about 41 minutes
Notes
..> idence
Johnathan Kluttz Single family residence
uTP50%
OFF
Ev f _ A LIf SITED .
`I;IME ONLY
Check Point-,,
m �
._ .. x• �Ya
610 E Center Ave, Mooresville, NC 28116-2678
1. Start out going EAST on E CENTER AVE toward
go 0.7 mi
CEDAR ST.
2. Turn RIGHT onto E IREDELL AVE / NC-3. Continue to
g 0 14.$ mi
3 follow NC-3.
3. Turn RIGHT onto NC-3 / DALE EARNHARDT BLVD / S
Y LOOP RD. Continue to follow NC-31 DALE EARNHARDT go 3.0 mi
BLVD.
j 4. Turn RIGHT onto CONCORD LAKE RD / NC-3.
go 5.1 mi
I Continue to follow NC-3.
s 5. NC-3 becomes BRANCHVIEW DR SE.
go 2.3 mi
`4 6. Turn LEFT onto OLD AIRPORT RD.
go 1.0 mi
......... ...
......
......... ....... ... .....
7. Turn LEFT onto COLFAX DR SE.
go 0.2 mi
8. COLFAX DR SE becomes THOMPSON DR.
go 0.4 mi
9. THOMPSON DR becomes ESSEX DR.
go 0.1 mi
http://www.mapquest.com/print 1/28/2010

Page 2 of 2
10, 2581 ESSEX DR is on the LEFT. go 0.0 mi
2681 Essex Dr, Concord, NC 28026-9090
Total Travel Estimate : 27.71 miles - about 41 minutes
Route Map tildq
http://www.mapquest.com/print 1/28/2010

State of; North -Carolina
Deparin)bht of Environment,
Health ands. Natural Resources
Division of Environmental Management
James. B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A., Preston Howard, Jr., P.E., Director
CLYDE L. SMITH
SMITH RESIDENCE(CLYDE L.)
2581 ESSEX DRIVE
CONCORD NC 28025
September 3,Q„7�9Y93
SMITH RESIDENCE(CLYDE L.)
Certificate of Coverage NCG550361
General Permit NCG550000
Formerly NPDES Permit NC0063231
Cabarrus County
Dear Permittee: � 016
Subject:
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 NC0063231. 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, EA. 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

Page.2
CLYDE L. SMITH
SMITH RESIDENCE(CLYDE L.)
Certificate of Coverage No. NCG550361
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 will be 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
Mooresville Regional Office, Water Quality Section at telephone number 704/ 663-1699, 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: Mooresville Regional Office
Central Files

R
STATE OF NORTH CAROLINA 1 .
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL USO-U—RCESa, any
DIVISION OF ENVIRONMENTAL MANAGEMENT
3tP28 993
GENERAL PERMIT NO. NCG550000
CERTIFICATE OF COVERAGE No. NCG550361 rj-VlSjaEd 4F Ej'el'jfivjaP;UyTAI 94A!1k6fj1if9T
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
SMITH RESIDENCE(CLYDE L.)
is hereby authorized to discharge treated domestic wastewater from a facility located at
SMITH RESIDENCE(CLYDE L.)
Cabarrus County
to receiving waters designated as the LITTLE COLD WATER CRK/YADKIN-PEE DEE
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

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STAFF REPORT AND RECOMMENDATIONS
PART I - INSPECTION OF PROPOSED WASTEWATER TREATMENT PLANT SITE
1. a. Place Visited: Jeff Gilbert Residence
b. Mailing Address: 467 Crestview Drive, S. E.
Concord, N. C. 28025
2. Date of Investigation: 7/22/85 Date of Report: 7/23/85
I'll �fo10
3. By: Michael L. Parker, Environmental Engineering Technician III
4. a. Persons Contacted: Mr. David Troutman, Cabarrus County Health Dept.
b. Phone No.: [phone]
5. Directions to Site: From the junction of Highway 601 Business (Union Road)
and SR 2635 (Old Airport Road) travel northeast on SR.2635 approximately 1.2
miles and turn left on Colfax Drive (No SR No.). Travel 0.1 mile and turn
left on Thompson Drive. Travel 0.3 miles and turn right on Essex Drive.
The site is on the left side of Essex Drive after traveling approximately
0.2 miles.
6. a. The coordinates to the proposed goint of effluent discharge are:
Latitude: 35024'11" Longitude: 80 32'11"
b. USGS Quad No.: F16NE (see attached map)
7. Size (land available for expansion and upgrading): There is ample area for
the construction of a suitable wastewater treatment system.
8. Topography: Hilly, 4-12% slopes.
9. Location of Nearest Dwelling: Two within 1000 feet of the proposed discharge
point.
10. Receiving Stream: Little Cold Water Creek
a. Classification: C
b. Minimum 7-Day, 10-Year discharge at site: Greater than 0.0 cfs
c. River Basin and Sub -Basin No.: Yadkin 030712
PART II - DESCRIPTION OF PROPOSED TREATMENT FACILITIES
1. Existing facilities: N/A.
2• .Proposed Facilities: Applicant proposes to construct a septic tank/sand filte
system followed by disinfection. The proposed site was denied a ground
absorption system by the Cabarrus County Health Department due to shallow soil
depth and internal drainage.
Since approximately 1/3 of this site is in a low-lying drainage area, the
actual construction of the sand filter should be above the 580' elevation
level to prevent possible flooding. The sand filter itself should have a
polyethylene lining to prevent groundwater infiltration. The effluent piping
should be extended directly to the center of Little Cold Water Creek.
From DEM guidelines, a WLA was developed for this proposed discharge and the
limits are as follows:

-2-
Flow
BOD
S
TSS
pH
Fecal Coliform
0.001 MGD
30.0 mg/l
30.0 mg/1
6-9 S.U.
1000/100 ml*
*Recommended by MRO. Receiving stream passes in close proximity to
several homes. Has easy public access.
PART III - EVALUATION AND RECOMMENDATIONS
1. Performance Evaluation: N/A.
2. 0 & M Evaluation: N/A.
2. Recommendations and/or Special Conditions: Pending review and approval of
plans and specifications, it is recommended that an NPDES Permit be issued.

DOW,
MIm MR W,
itIA
WIN
it
dll
n_41 ify,
FAMES
IONIC

Date:
AZ5
F a c I I.F.ty-Name: ��`S`i4�.tletPermi t:
Receiv.i.ng S-tream: Mlle 0/0/AJWAO—e A2226lass: c Sub -Basin: D3`a7"OZ
County: `�����uS RegIona.l Oftice:
Reference USGS-Ouad: t,1g, Existing: Proposed:
Elevation: Drainage Area:
Hydrologic Group: Design Temperature:
Slope: ; Comments:
74
RECOMMENDED EFFLUENT LIMITS
Wa3tefloW
(gpd):
O�
GODS
(mg/I):
O
NH3=N
Cmg/1):
D.O.
pH
(mg / 1) :
(SU) :
6..
Fecal Coli
C/100m1):
� Q Q)
TSS
Cmg/1):
3 0
RECOMMENDED BY-
APPROVED BY:
Regional Engineer:
Data:OF
23
f .
Date:
`Regional Supervisor: _'W Datsa
ROUTE to Technical Support Group and Permits & Engineering Unit
(Encl-ose copy of USGS topog-raphical map showing location of dis•eharger)

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State of North Carolina
Department of Nattttaale, :5, sources and Community Development
t. BvlslUia U 51217vdtr %Sal�si "s y Street • Raleigh, North Carolina 27611
James C Martin, Coif r .Sst,N�r //A 4� r S. Thomas Rhodes, Secretary
GavGa�o / 41,
OW zs
Subject: Application for NFPES Permit Nod9�3�3,
County
Receipt of the 'fallowing documents• is hereby acknowledged:. _:.:..:... ,.:.:,�•�-:.;�
--X—APplication.Form
Engineering Proposal (for proposed control facilities)
_. Request for permit renewal
Other
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 22--
yQ h Q I�MG� !`✓ G��lettV .1f�.rr7�'/S�(
• Zf the application 8 not made comp ete wi in -thirty (30) days, it. be returned...
to you and may be.resubmitted.when complete. :
This application has been assigned to ,/ � Q/�/ f°
(919/733-5083) of our Permits unit for.review and preparation 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 permit. 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.
TSerely yours,
ae4x� -
Arthur Mouberry, P.E.
eo�Supervisor, Permits and Engineering
cclUa0z Regional Supervisor
An Equal Opportunity / Affirmative Action Employer

NATIONAL POLLUTANT DISCHARGE ELIMINAIIUN SYSTEM
APPLICATION FOR PERMIT TO DISCHARGE — SHORT FORM G FOR
AGENCY
USE
To be filed only by services, wholesale and retail trade,
and other commercial establishments including vessels
Do not attempt to complete this form without reading the accompanying instructions
Please print or type
1. Name, address, and telephone number of facility producing discharge
A. Name ,F-F �1 E2—F
APPLICATION NUMBER
C6Q63��1
DATE RECEIVED
YEAR M0. DAY
B. Street address L[i 3 o C=sSC 2.
�6I�,�-i S 1� n ��eI-
C. City PC C,)-rA✓T_CL
D. State A21 L1
E. County 0—A-i)13220S
F. ZIP
G. Telephone No. � t �- L— /
C�G✓2P_ fin// �C�.eE`ss
Area qII
96 Code / ��O tV
�
9 < C4_" U//il�C
2. S I C ®
(6
(Leave blank)
z
3. Number of employees iGn-) 11
"C'F
/
4. Nature of business �EE -�4T r/c�
C. DFPT. Or I: .,..,..
k�i'J(p(mp7��7egnpl(1jR([LS r�?`O
here if
�JNJWu4.11'1111' JVbJ�LJQII�.
5. (a) Check discharge occurs all year a°, or
(b) Check the month(s) discharge occurs:
? 5 E -'
1. ❑ January 2. 0 February 3. o March - 4, o April
5. 0 May
6. ❑ June 7.0 July B. 0 August 9.0 September
10. ❑ October . EF�i��t'p,tllsfi gtiPd'.1Gi.ga ;i
ff
I I. ❑ November. 12.0 December
(c) How many days per week:
1.01 2.0 2-3 3.0 4-5 4.06-7
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-S999
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)
(B)
(9)
(10)
A. Sanitary, daily
average
B. Cooling water,etc.,
daily average
C. Other discharge.(s),
daily average;
Specify
UN
7 .
D. Maximum per. operat-'-
ing day for combined
ERING
& V404E._
discharge (all types)
PERI�flITS

7. If any 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)
56000-6r:mdre
:(5)
A. Municipal sewer system
II• Iln�lrryrnunrl wi.i
C. Septic tank
D. Evaporation lagoon or pond
E. Other, specify:
8. Number o eparate discharge points:
A. 1 B. a2-3 C.O 4-5 D.o 6 or more
9. Name of receiving water or waters
10. Does your discharge contain or is it possible for your discharge to contain
one or more of the following substances added as a result of your operations,
activities; or processes: ammonia, cyanide, aluminum, beryllium, cadmium,
chromium, copper, lead, mercur nickel. selenium, zinc, phenols, oil and -
grease7ye
d chlorine (residual. .
s B.o no
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
Title
Date A plica ion Si ed
Signafure �p 1`l1ant
North Carolina General Statute 143-215.6 (b) (2) provides that: Any person who'knowiriglp 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 kubwly renders. inaccurate any icecording or monitorirkg,device or method required to be
operated or maintained under Article 21;or.regulations•of the Environmental, Management_Comission
implementing" that- Article, shal3��be: guj-3 tv: -of a misdemeanor punishable by a •fi> a -�npt ,td ;exceed
$10,000, or by imprisonment not to. exceed six months, - or by both. (18 U.S.C.-`-Se X03 'provide:
a punisiment bya fine ot'_'Aot more than 810,000 or -imprisonment not more than'5.yea= ;'61 both,
for a similar offense.)

v
Cabarrus County Health Department
715 Cabarrus Avenue W. P.O. Box 1149 • Concord, N. C. 28026 - 1149 Area Code 7041786-8121
William F. Pilkington, Health Director
,TApri l 4, 1985
I "
Rex Gleason
N, C. Dept. of` --Natural Resources
Division of -Environmental Management
Post Office Box 950
Mooresville, N, C. 28115
To Whom 1t May, Concern;
C). <�
n,,J� e.�
Lot 30, English_[ foods, subdivision. in Cabarrus County Capplica-
ti.on ##85-144) does not meet the. requirements for any type of ground
absorption,waste T4atex disposal system, This lot is unsuitable
bacauae of shallow, soil depth -to saprolite and internal drainage,
This lot is, bordered on oneside by- Little- Cold -dater Creek,
DMT/esw
&incerely-o
�( U
David M, Troutman
Sanitarian
An Equal Opportunity Employer

Cabarrus County Health Department
715 Cabarrus Avenue W. • P.O. Box 1149 • Concord, N. C. 28025 • Area Code 7041786-8121
William F. Pilkington, Health Director
r•4arcN a, 193;7)
� ✓p't 4yCa j� � ��1`�
%
Carol and ! e = f I ^ _ r � Ga�s�A�� at
Dear "r. 1,17-r. Ri Irr-!rt
On _ i'a rch ^ 19;5 Mr. Kenneth Hinson, Sanitarian
Specialist, re-evaluated your property Iocated at-
r,.�! i sh log _
The purpose of this re—evaluation was to determine whether or not the
sanitarian had made the right decision in deciding that your property
was unsuitable for a septic tank sewage disposal system.
Mr. Hinson has concluded that in his opinion the sanitarian made the
right decision. If you would like to further appeal this matter,
please contact Mr. Hinson or Mr. Bob Farris who will -arrange for the
representative of the State to come down and affirm or overrule our
decision on this property.
If you have any questions, please feel free to call on us at any time.
Si/ncereIy,,.
William F. Pilkington
Health Director
An Equal Opportunity Employer

Cabarrus County Health Department
715 Cabarrus Avenue W. • P.O. Box 1149 • Concord, N. C. 28025 • Area Code 7041786-8121
William F. Pilkington, Health Director
June 13, 1985
V
Mr. Rex Gleason
C/O NRCD
919 North Main Street
Post Office Box 950
LLE
Mooresville N. C. 28115-0950 iofot�OFFI
Dear Mr. Gleason:
I am writing you in reference to your -letter addressed to Mr.
Jeff Gilbert of Concord dated May 15, 1985, concerning -the suitability
of lot 30 in English Woods subdivision for a subsurface wastewater
treatment system.
Lot 30 in English Woods subdivision .(application #85-144) is
considered unsuitable for any type of ground absorption.system that
is currently being permitted by this department. Problems with
insufficient soil depth.to saprolite and internal drainage do exist
on this lot making it unsuitable.
If there are anyquestions regarding this matter, please feel
free to call me between 8 A. M. and 9 A. M. weekdays.
sincerely,
DMT/.esw
David M. Troutman
Sanitarian
An Equal Opportunity Employer

State of North Carolina
Department of Natural Resources and Community Development
Division of Environmental Management
512 North Salisbury Street • Raleigh, North Carolina 27611
James G. Martin, Governor
S. Thomas Rhodes, Secretary
Mr. Jeff Gilbert
99 Church Street
Concord, NC 28025
Dear Mr. Gilbert:
ISO � S-A., magust
O o�: £tavtF.osteaE�P�
INV5; '
SUBJECT:
1, 1985 011
Itn'
Permit No. NCO063231
Gilbert Residence
Cabarrus County
R. Paul Wilms
Director
In accordance with your application for discharge Permit received June 5,
1985, we are forwarding herewith the Subject State-NPDES Permit. This permit is
issued pursuant to the requirements of North Carolina General Statute 143-215.1 and
the Memorandum of Agreement between North Carolina and the U. S. Environmental
Protection Agency dated December 6, 1983.
If any parts, requirements, or limitations contained in this Permit are
unacceptable to you, you have the right to an adjudicatory hearing before a hearing
officer upon written demand to the Director within 30 days following receipt of
this Permit, identifying the specific issues to be contended. Unless such demand
is made, this Permit shall be final and binding.
Please take notice that this Permit is not transferable. Part II, B.2.
addresses the requirements to be followed in case of change in ownership or control
of this discharge.
This Permit does not affect the legal requirement to obtain other Permits
which may be required by the Division of Environmental Management. If you have any
questions concerning this Permit, please contact Mr. Mack Wiggins, telephone
919/733-5083.
Sincerely,
R. Paul Wilms
cc: Mr. Jim Patrick, EPA
a�Mo�res�rl�l lle�oriSue��r� sc�
Pollution Prevention Pays
P.O. Box 27687, Raleigh, North Carolina 27611-7687 Telephone [phone]
An Frmal Onnnrninity AFfirmaHve Artinn Fmnlnver

Permit No. -NC 0063231
STATE OF NORTH CAROLINA
DEPARTHENT OF NATURAL RESOURCES 6 COMMUNITY DEVELOPMENT
DIVISION OF ENVIRONMENTAL MANAGEMENT �J
PERMIT
To Discharge Wastewater Under the KATIOUAL
POLLUTANT DISCHARGE ELIMINATION SYSTEM!
In o fance with the provisions of North Carolina General Statute 143-215.1,
other lawful standards and regulations promulgated and adopted by the Borth Carolina
Environmental Kanagemeat CoamLesiron, and the Federal Water Pollution Control Act, as
amended,
Jeff Gilbert
Is hereby authorized to discharge wastewater f,= a facility 16cated at
Jeff Gilbert Residence
Essex Drive, -Lot #30
Cabarrus County
to receivimg waters designated as Little Cold Water Creek in the Yadkin Pee -Dee
River Basin -
in ance with of meat I iaitat%as, monitoring restuirP L.. and other
conditions set forth in its 1. 11, and M hereof_
This -permit shall become effective August 1, 1985
This permit and the authorization to discharge shall expire at afdoig�t
on July 31, 1990 1
Signed this day of
August 1, 1985
RIGINAL SIGNED BY
ART1-iUM MO'k 9SERRY•
R. Paul Wilms, Director
Division of Environmental Kanages
By Authority of the Enviromental
Kano ceaent Coma�fasioa
M1&I1

Permit No. NCO063231
SUPPLEMENT TO PERMIT COVER SHEET
Jeff Gilbert Residence
is hereby authorized to:
1. Enter into a contract for construction of a wastewater
treatment facility, and
2. Make an outlet into Little Cold Water Creek, and
3. After receiving an Authorization to Construct from the
Division of Environmental Management, construct and
operate a 0.001 MGD wastewater treatment facility located
at Essex Drive, Lot #30, Cabarrus County (See Part III,
condition No. B of this Permit), and
4. Discharge from said treatment works into Little Cold
Water Creek which is classified Class "C" waters, and is
located in the Yadkin Pee -Dee River Basin.

Z
w
A. ( I. EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS Final
W ng the period beyinning�n the effective date of the Permitand lasting until expiration,
• the penmittee is authorized to discharge from outfall(s) serial nwnber(s) ooi.
Such discharges shall be limsited and monitored by the permittee as specified below:
Effluent charcttristics Oischarae hiLitation Monitoring Requirements
KWU(. s Other -Units s ecif Measurement S 1e Samle
Monthly �v9s. .�..,. '� e,g Location
Flow 0.001 MGD
BOD, 5Day, 200C 30.0 mg/l 45.0 mg/1
Total Suspended Residue 30.0 mg/l 45.0 mg/l
NH as N
Fetal Coliform (geometric mean)
Residual Chlorine
Temperature
1000.0/100 ml 2000.0/100 ml
The pH shall not be less than 6.0 standard units nor greater than 9.o
standard units
There shall be no discharge of floating solids or visible foam, in other than trace amounts.

PART I
"Act" used -herein means the Federal Water Pollution Control Act, As
Amended.
"DEM" used herein means the Division of Envirornnental Management of
the Department of Natural Resources and Community Development.
"EMC" used herein means the North Carolina Environmental Management
Commission.
Definitions
a. The monthly average, other than for fecal coliform bacteria, is
the arithmetic mean of all the composite samples collected in a
one -month period. The monthly average for fecal coliform bacteria
is the geometric mean of samples collected in a one -month period.
b. The weekly average, other than for fecal coliform bacteria, is the
arithmetic mean of all the composite samples collected during a
one -week period. The weekly average for fecal coliform bacteria
is the geometric mean of samples collected in a one -week period.
c. Flow, M3/day (MGD): The flow limit expressed in this permit is the
24-hour average flow, averaged monthly. It is determined as the
arithmetic mean of the total daily flows recorded during the calendar
month.
d. Arithmetic Mean: The arithmetic mean of any set of values is the
summation of the individual values divided by the number of indi-
vidual values.
e. Geometric Mean: The geometric mean of any set of values is the Nth
root of the product of the individual values where N is equal to the
number of individual values. The geometric mean is equivalent to
the antilog of the arithmetic mean of the logarithms of the indi-
vidual values. For purposes of calculating the geometric mean,
values of zero (0) shall be of
to be one.(1).

M
PART II
A. MANAGEMENT REQUIREMENTS
1. Change in Discharge
All discharges authorized herein shall be consistent with the terms
and conditions of this permit. The discharge of any pollutant
identified in this permit more frequently than or at a level in
excess of that authorized shall constitute a violation of the
permit. Any anticipated facility expansions, production increases,
or process modifications which will result in new, different, or
increased discharges of pollutants must be reported by submission
of a new NPDES application or, if such changes will not violate the
effluent limitations specified in this permit, by notice to the DEM
of such changes. Following such notice, the permit may be modified
to specify and limit any pollutants not previously limited.
2. Facilities Operation
The permittee shall at all times maintain in good working order and
operate as efficiently as possible all treatment or control facili-
ties or systems installed or used by the permittee to achieve com-
pliance with the terms and conditions of this permit.
3. Adverse Impact
The permittee shall take all reasonable steps to minimize any adverse
impact to navigable waters resulting from noncompliance with any
effluent limitations specified in this permit, including such accel-
erated or additional monitoring as necessary to determine the nature
and impact of the noncomplying discharge.
4. Bypassing
Any diversion from or bypass of facilities necessary to maintain com-
pliance with the -terms and conditions of this permit is prohibited,
except (i) where unavoidable to prevent loss of life or severe
property damage, or (ii) where excessive storm drainage or runoff
would damage any facilities necessary for compliance with the
effluent limitations and prohibitions of this permit. The permittee
shall promptly notify the Water Quality Section of DEM in writing of
each such diversion or bypass.
5. Removed Substances
Solids, sludges, filter backwash, or other pollutants removed in the
course of treatment or control of wastewaters shall be disposed of in
a manner such as to prevent any pollutant from such material from
entering waters of the State or navigable waters of the United
States.

PART II
6, Power Failures
In order to maintain compliance with the effluent limitations and
prohibitions of this permit, the permittee shall either:
a. Provide an alternative power source sufficient to operate
the wastewater control facilities;
or, if such alternative power source is not in existence,
b. Halt, reduce, or otherwise control production and/or all dis-
charges from wastewater control facilities upon the reduction,
loss, or failure of the primary source of power to said waste-
water control facilities.
B. RESPONSIBILITIES
1. Right of Entry
The permittee shall allow the Director of the Division of.Environ-
mental Management, the Regional Administrator, and/or their author-
ized representatives, upon the presentations of credentials:
a. To enter upon the permittee's premises where an effluent
source is located or in which any records are required to
be kept under the terms and conditions of this permit; and
b. At reasonable times to have access to and copy any records
required to be kept under the terms and conditions of this
permit; to inspect any monitoring equipment or monitoring
.method required in this permit; and to sample any discharge
of pollutants.
2. Transfer of Ownership or Control
This permit is not transferable. In the event of any change in con-
trol or ownership of facilities from which the authorized discharge
emanates or is contemplated, the permittee shall notify the prospec-
tive owner or controller by letter of the existence of this permit
and of the need to obtain a permit in the name of the prospective
owner. A copy of the letter shall be forwarded to the Division of
Environmental Management.
3. Permit Modification
After notice and opportunity for a hearing pursuant to NCGS 143-215.1
(b)(2) and NCGS 143-215.1(e) respectively, this:permit may be modi-
fied, suspended, or revoked in whole or in part during its term for
cause including, but not limited to, the following:

PART II
a. Violation of any terms or conditions of this permit;
b. Obtaining this permit by misrepresentation or failure to
disclose fully all relevant facts; or
c. A change in any condition that requires either a temporary
or permanent reduction or elimination of the authorized
discharge.
4. Civil and Criminal Liability
Except as provided in permit conditions on "Bypassing" (Part II,
A-4) and "Power Failures (Part II, A-6),'nothing in this permit
shall be construed to relieve the permittee from civil or criminal
penalties for noncompliance pursuant to NCGS 143-215.6 or Section
309 of the Federal Act, 33 USC 1319.
5. Property Rights
The issuance of this permit does not convey any property rights in
either real or personal property, or any exclusive privileges, nor
does it authorize any injury to private property -or anyInvasion of
personal rights, nor any infringement of Federal, State, or local
laws or regulations.
6. Severability
The provisions of this permit are severable, and if any provision of
this permit,.or the application of any provision of this permit to
any circumstance, is held invalid, the application of such provision
to other circumstances, and the remainder of this permit shall not
be affected thereby.
7. Expiration of Permit
Permittee is not authorized to discharge after the expiration date.
In order to receive authorization to discharge beyond the expiration
date, the permittee shall submit such information, forms, and fees
as are required by the agency authorized to issue permits no later
than 180 days prior to the expiration date. Any:discharge without
a permit after the expiration will subject the permittee to enforce-
ment procedures as provided in NCGS 143-215.6 and 33 USC 1251 et seq.,.

PART III
A. PREVIOUS PERMITS
All previous State water quality permits issued to this facility,
whether for construction or operation, or discharge, are hereby
revoked by issuance of this permit. The conditions, requirements,
terms, and provisions of this permit authorizing discharge under the.
National Pollutant Discharge Elimination System govern discharges
from this facility.
B. CONSTRUCTION
No construction of wastewater treatment facilities or additions thereto
shall be begun until Final Plans and Specifications have been submitted
to. the Division of Environmental Management and written approval and
Authorization to -Construct have been issued. If no 'objections to Final
Plans and Specifications have been made by the DEM.after 30 days follow-
ing.receipt of the plans or issuance of this permit, whichever is latter,
the plans may.be considered approved and construction authorized.
C. SPECIAL CONDITIONS
1. The Permittee shall be responsible for the following items regard-
ing the maintenance of the treatment system:
a. Septic tanks shall be maintained at all times to prevent
seepage of sewage or effluents to the surface of the ground.
b. Septic tanks need routine maintenance and should be checked
at least yearly to determine if solids need to be removed
or other maintenance performed.
c. Contents removed from septic tanks shall be discharged into
an approved.sewer system, buried or plowed --under at an
approved location within 24 hours, or otherwise disposed of
at a location and in a manner approved by the State or local
agency.
2. The permittee shall properly connect to an operational publicly -
owned wastewater collection system within 180 days of its availability
to the site.

Permit No. NCO063231
STATE OF NORTH CAROLINA
N_, DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
Al",�ggp DIVISION OF ENVIRONMENTAL MANAGEMENT
PERMIT
TO DISCHARGE WASTEWATER UNDER THE
\�1�5X" \ 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,
Mr. Jeffery A. Gilbert
is hereby authorized to discharge wastewater from a facility located at
Jeffery A. Gilbert Residence
2581 Essex Drive
southwest of Cold Springs
Cabarrus County
to receiving waters designated as Little Cold Water Creek in the Yadkin -Pee Dee River Basin
in accordance with effluent limitations, monitoring requirements, and other conditions set forth in
Parts I, H, and III hereof.
This permit shall become effective
This permit and the authorization to discharge shall expire at midnight on October 31, 1994
Signed this day
George T. Everett, Director
Division of Environmental Management
By Authority of the Environmental Management Commission

Permit No. NCO063231
SUPPLEMENT TO PERMIT COVER SHEET
Mr. Jeffery A. Gilbert
is hereby authorized to:
1. Continue to operate an existing wastewater treatment system consisting of a septic tank, and
recirculation sandfilter located at Jeffery A. Gilbert Residence, 2581 Essex Drive, southwest of
Cold Springs, Cabarrus County (See Part III of this Permit), and
2. Discharge from said treatment works at the location specified on the attached map into Little Cold
-Water Creek which is classified Class C waters in the Yadkin -Pee Dee River Basin.

SV•,
\ 71
LAND f ! MI
'NROF_ 30 MI.
CHARL(2'TE 21 M7./4 32'30"
I MILE
)00 6000 7000 rEE:
1 KILOMETER
!929
Y STANDARDS
:VEY
3MIA 22092
AVAILABLE ON REQUEST
—\SLN AZ6� S\Tl.
F 16 ti��
v1J
_ ■
QUADRANGLE LOCATION
Revisions shown in purple and woodland compiled in
cooperation with State of North Carolina agencies from
aerial photographs taken 1984 and other sources: This
• • INTERIOR -GEOLOGICAL SURVEY, RESTON, VIRGINIA-1987
544 545000 E. 8C
ROAD CLASSIFICATION
Primary highr;ay, Light -duty road, hard or
hard surface improved surface —
Secondary hihway,
hard surface Unimproved road
�) % Inter_:ate Route _ .; U. S. Route '\.. State Route
CONCORD, N. C.
35080-D5-TF-024
1969
PHOTOREVISFD 19II,

A. (). EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS FINAL Permit No. NCO063231
During the period beginning on the effective date of the permit and lasting until expiration, the Permittee is authorized to discharge from
outfall(s) serial number 001. Such discharges shall be limited and monitored by the permittee as specified below:
Effluent Characteristics
Flow
BOD, 5 day, 200C
Total Suspended Residue
NH3 asN
Fecal Coliform (geometric mean)
Total Residual Chlorine
Temperature
Discharge Limitations
Units (specify)
Monthly Avg, Weekly Avg,,
0.001 MGD
30.0 mg/1 45.0 mg/l
30.0 mg/l 45.0 mg/I
200.0 /100 ml 400.0 /100 ml
Monitoring Requirements
Measurement sample *Sample
Frequency Tv"e Location
The chlorinator shall be inspected weekly to ensure there is an ample supply of chlorine tablets for continuous disinfection of the effluent.
The pH shall not be less that 6.0 standard units nor greater than 9.0 standard units.
There shall be no discharge of floating solids or visible foam in other than trace amounts.

i.
eo
4ftON OFE'VVIIRROJR-ec;NMMENT\AAL 4A1946E4E,4
DEC 11 1989
��,
)r100RE OM
2F1ilOryA< State of North Carolina
Department of Environment, Health, and Natural Resources
Division of Environmental Management
512 North Salisbury Street • Raleigh, North Carolina 27611
James G. Martin, Governor
William W. Cobey, Jr., Secretary
JEFFREY A. GILBERT
GILBERT RESIDENCE (JEFF
99 CHURCH STREET
CONCORD NC
Dear JEFFREY A. GILBERT
December 6, 1989
28025
Subject: NPDES Permit No. NCO063231
CABARRUS
R. Paul Wilms
Director
Our files indicate that the subject permit for a wastewater discharge to the
surface water expires on 900731. GS 143-215.1(c) requires that an application for
renewal must be filed 180 days prior to the expiration date. We have not received an
application for renewal from you as of this date.
A renewal application shall consist of a letter requesting renewal along with the
appropriate completed and signed application form, submitted in triplicate, referenced
in Title 15 of the North Carolina Administrative Code, Subchapter 2H, .0105. Primary
industries listed in Appendix A of Title 40 of the Code of Federal Regulations, Part
122 (40 CFR Part 122), shall submit a priority pollutant analysis that is performed in
accordance with 40 CFR Part 122.21. A processing fee must be submitted with the
application. Please find attached a copy of the 15 NCAC 2B .0105(b) regulations. The
processing fee for your facility is based on the design or permitted flow, whichever
is appropriate, listed in the first five categories of facilities. No facility is
allowed to submit a fee for the general permits listed in the fee schedule at this
time since EPA has not approved our general permit. Also the Environmental Management
Commission adopted rules on August 1,1988, requiring the payment of an annual fee for
most permitted facilities (See Attached). You will be billed separately for that fee
(if applicable), after your permit is approved.
This matter should be given prompt attention in that continued discharge after
the permit's expiration, without the filing of a complete and timely application for
renewal, constitutes discharge without a permit and is a violation of GS 143-215.1(a)
and the Federal Clean Water Act of 1977. The application for renewal should be
submitted to:
Permits and Engineering Unit
Division of Environmental Management
P. 0. Box 27687
Raleigh, North Carolina 27611-7687
P.O. Box 27687, Raleigh, North Carolina 27611-7687 Telephone [phone]
An Equal Opportunity Affirmative Action Employer

information, please contact me at 919 733-7015.
Sincerely,
Original :Signed By
M. Dale 4vercash
M. Dale Overcash, P.E.
Supervisor, NPDES Permits Group
cc: MOORESVILLE Regional Office
Central Files

d.wsurpo
ti y^•
J
State .of North Carolina
Department of Environment, Health, and Natural Resources
Mooresville Regional Office
James G. Martin, Governor Albert F. Hilton, Regional Manager
William W. Cobey, Jr., Secretary
DIVISION OF ENVIRONMENTAL MANAGEMENT
October 6, 1992
Mr. Clyde L. Smith
2581 Essex Drive
Concord, North Carolina 28025
Subject: NPDES Permit No. NCO063231
Smith Residence
formerly issued to
Jeffrey A. Gilbert
Cabarrus County, NC
Dear Mr. Smith:
Our records indicate that NPDES Permit --No. NCO063231 was
issued on October.l, 1992 for the discharge of wastewater to the
surface waters of the State from your facility. The purpose of.
this letter is to advise you of the importance of the Permit and
the liabilities in the event of failure to comply with the terms
and conditions of the Permit. If you have not already done so,
it is suggested that you thoroughly read the Permit. Of
particular importance is Page 4.
Page 4 sets forth the effluent limitations and monitoring
requirements for your discharge(s). Your discharge(s) must not
exceed any of the limitations set forth. The section headed
"Monitoring Requirements" describes the -measurement frequencies,
sample types and sampling locations. Upon commencement of your
discharge (or operation), you must initiate the required
monitoring. The monitoring results must be entered on the
reporting forms furnished to you by this Agency. If you have not
received these forms, they should be arriving shortly. If you
fail to receive the forms, please contact this office as quickly
as possible. I have enclosed a sample of the "Effluent"
reporting form (DEM Form MR-1), plus instructions for completing
the form. 'It is imperative that all applicable parts'be
completed, and the original and one copy be submitted as
required.
The remaining Parts of the Permit set forth definitions,
general conditions and special conditions applicable to the
operation of wastewater treatment facilities and/or discharge(s).
P.O. Box 950, 919 North Main Street, Mooresville, N.C. 28115-0950 • Telephone [phone] • FAX [phone]
An Equal Opportunity Affirmative Action Employer

Mr. Clyde L. Smith
Page Two
October 6, 1992
The conditions include special reporting requirements in the
event of noncompliance, bypasses, treatment unit/process
failures, etc. Also addressed are requirements for a certified
wastewater treatment plant operator if" you are operating
wastewater treatment facilities. Any changes in operation of
wastewater treatment facilities, quantity and type of wastewater
being treated or discharged, expansions and/or upgrading of
wastewater treatment facilities must be permitted or approved by
this Agency.
Failure to comply with the terms and conditions of an NPDES
Permit subjects the Permittee to enforcement action pursuant to
Section 143-215.6 of the North Carolina General Statutes. A
civil penalty of up to $10,000 per violation plus criminal
penalties may be assessed for such violations. If you find at
any time that you are unable to comply with the terms and
conditions of the Permit, you should contact this Office
immediately. A Consent Order may be necessary while pursuing
action to obtain compliance.
As a final note, an NPDES Permit is normally issued for a
five-year period. Permits are not automatically renewed.
Renewal requests must be submitted to this Agency no later than
180 days,prior to expiration. Please make note of the expiration
date of your Permit. This date is set forth on Page 1 of the
Permit. Also note that NPDES Permits are not transferable. If
you, as the Permittee, cease to need this Permit, then you should
request that the Permit be rescinded.
As mentioned previously, the purpose of this letter is to
advise you of the importance of your NPDES Permit. Please read
the Permit and contact this Office at 704/663-1699 in Mooresville
if you have any questions or need clarification. We look forward
to providing any assistance.
Sincerely,
D. Rex Gleason, P. E.
Water Quality Regional Supervisor
Enclosure
DRG:ssl

I�
C. gy pi.orN
1 ��i,JUNx�
%' � Oh:c�9:4t .1E9�a�laEit9Et�
su 1992
sawn WE
imail-tiEwa ORat
State of North Larouna
Department of Environment, Health and Natural Resources
Division of Environmental Management
512 North Salisbury Street • Raleigh, North Carolina 27626-W35
James G. Martin, Governor A. Preston Howard, Jr., P.E.
William W. Cobey, Jr., Secretary Acting Director
October 1, 1992
Clyde L. Smith
2581 Essex Drive
Concord, NC 28025
Dear Mr. Smith:
Subject: NPDES No. NCO063231
Smith Residence
formerly Issued to
Jeffrey A. Gilbert
Cabarrus County
In accordance with your request received September 10, 1992, we are forwarding
herewith the subject permit now issued to you. The only changes In this permit are in name
and ownership as well as update the permit to current DEM regulations. This permit is issued
pursuant to the requirements of North Carolina General Statute 143-215.1 and the
Memorandum of Agreement between North Carolina and the U. S. Environmental . Protection
Agency dated December 6, 1983.
If any parts, measurement frequencies or sampling requirements contained in this
permit are unacceptable to you, you have the right to an adjudicatory hearing upon written
request within thirty (30) days following receipt of this letter. This request must be in the
form of a written petition, conforming to Chapter 150E of the North Carolina General Statutes,
and filed with the Office of Administrative Hearings, Post Office Drawer 27447, Raleigh, North
Carolina 27611-7447. Unless such demand is made, this decision shall be final and binding.
Please take notice that this permit is not transferable. Part II, E.4. addresses the
requirements to be followed in case of change in ownership or control of this discharge.
This permit does not affect the legal requirement to obtain other permits which may be
required by the Coastal Area Ironmental Ma agementManagement
Act or any other Federal required
orLocal governmental
Division
Land Resources,, rnmen al
permit that may be required.
Pollution Prevention Pays
P.O. Box 29535, Raleigh, North Carolina 27626-0535 Telephone [phone]
An Equal Opportunity Affirmative Action Employer

aw
Page 2
October 1,1992
If you have any questions concerning this permit, please contact Susan Robson at
telephone number 919/733-5083.
Sincerely,
. Preston Howard, Jr., P.E.
Acting Director
cc: Mr. Jim Patrick, EPA
urges I e = egional Office
Compliance
Central Files
Technical Support Branch
Kim Brantley

Permit No. NCO063231
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
DIVISION OF ENVIRONMENTAL MANAGEMENT
PERMIT
TO DISCHARGE WASTEWATER 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,
Mr. Clyde L. Smith
is hereby authorized to discharge wastewater from a facility located at
Smith Residence
2581 Essex Drive
southwest of Cold Springs
Cabarrus County
to receiving waters designated as Little Cold Water Creek in the Yadkin -Pee Dee River Basin
in accordance with effluent limitations, monitoring requirements, and other conditions set forth in
Parts I, H, and III hereof.
This permit shall become effective October 1, 1992
This permit and the authorization to discharge shall expire at midnight on October 31, 1994
Signed this day October 1,1992
; Preston Howard, Jr., Acting Director
Division of Environmental Management
By Authority of the Environmental Management Commission

I Permit No. NCO063231
SUPPLEMENT TO PERMPT COVER SHEET
Mr. Clyde L. Smith
is hereby authorized to:
1. Continue to operate an existing wastewater treatment system consisting of a septic tank, and
recirculation sandfilter located at Smith Residence, 2581 Essex Drive, southwest of Cold
Springs, Cabarrus County (See Part III of this Permit), and
2. Discharge from said treatment works at the location specified on the attached map into Little Cold
Water Creek which is classified Class C waters in the Yadkin -Pee Dee River Basin.

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li r. r. ".:`. r.i1� - \ �• .. ,;� Y` � 1 0 - - i.r; .f••�� ��``\\'t Cerni v
$'. �'%/i,, �IIh�. � �Il�^2 - i j\; -: ,'jam• ^ �`.o.\`. �.%� eteis h. -1r.
4\ � ' ' � �'h /_ I/S�L•� 1111 l {J� \ �' ' ' "b�• I -� yj' �66 -6Sac. • `,-_ "et-. � '�1\ II
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\.,,
,�/ �1 . , i/i.. 1:'• OGIUL SURVEY. RESTON. VIRGINIA-19e7 80 � 3 _. .1 • 1.: .• ,.. f%" 0 IHTE RIOR--GEOL $45000 E.
MI CHARLOT'f 21 MI -. 32'30" 542
ROAD CLASSIFICATION
Light -duty road. hard or
1 MILE Primary highr,ay' improved surface
hard surface
6" 70G7 FEE7
mE=__ O — �\SLNARCG� S1T� Secondaryhl;hwaY' � road
t xILoMETEN hard surface
`,t
Route
1 - Intersate Rout 1� `]
l,Ay $ 1490
i N C'1
- CONCORD, N. C.
bE0eX-W-YF-024
InftDS
Rev!slocs sho:•,II In purple and woodland compiled In 1969
20`J2 coop_ra; _., r,lt:n. State of North Carollna-agencles from PHQTORF-VIS` D >9t3�
:B E ON 9EC'JEST aPr,al : - ,ra hs taken l ' :; ; .,-i ethers :rco; Th's

A (). EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS FINAL
Permit No. NCO063231
. During the period beginning on the effective date of the permit and lasting until expiration, the Permittee is authorized to discharge from
outfall(s) serial number 001. Such discharges shall be limited and monitored by the permittee as specified below:
Effluent Charecterlstic• Discharge Llmltatlont Monitoring Requlrementa
Units JaRecifv; Measurement Somals *Sample
Monthly Avg Weekly Avg. Freguencv Tvas Location
Flow 0.001 MGM
BOD, 5 day, 200C 30.0 mg/I 45.0 mg/I
Total Suspended Residue 30.0 mg/1 45.0 mg/1
NH3asN
Fecal Coliform (geometric mean) _ 200.0 /100 ml 400.0 /100 ml
Total Residual Chlorine
Temperature
The chlorinator shall be inspected weekly to ensure there is an ample supply of chlorine tablets for continuous disinfection of the effluent.
The pH shall not be less that 6.0 standard units nor greater than 9.0 standard units.
There shall be no discharge of floating solids or visible foam in other than trace amounts.

PART I
"Act" used herein means the Federal Water Pollution Control Act, As
Amended.
"DEM" used herein means the Division of Environmental Management of
the Department of Natural Resources and Community Development.
"EMC" used herein means the North Carolina Environmental Management
Commission.
Definitions
a. The monthly average® other than for fecal coliform bacteria, is
the arithmetic mean of all the composite samples collected in a
one -month period. The monthly average for fecal coliform bacteria
is the geometric mean of samples collected in a one -month period.
b. The weekly average,' other than for fecal coliform bacteria, is the
arithmetic mean of all the composite samples collected during a
one -week period. The weekly average for fecal coliform bacteria
is the geometric mean of samples collected in a one -week period.
C. Flow, M3/day (MGD): The flow limit expressed in this permit is the
24-hour average flow, averaged monthly.. It is determined as the
arithmetic mean of the total daily flows recorded during the calendar
month.
d. Arithmetic Mean: The arithmetic mean of any set of values is the
summation of the individual values divided by the number of indi-
vidual values.
e. Geometric Mean: The geometric mean of any set of values is the Nth
root of the product of the individual values where N is equal to the
number of individual values.. The geometric mean is equivalent to
the antilog of the arithmetic mean of the logarithms of the indi-
vidual values. For purposes of calculating the geometric mean,
values of zero (0) shall be considered to be one (I).

I
PART 11
A. !MANAGEMENT REQUIREMENTS
1. Change in Discharge
- All discharges authorized herein shall be consistent with the terms
and conditions of this permit. The discharge of any pollutant
identified in this permit more frequently than.or at a level in
excess of that authorized shall constitute a violation of the
permit. Any anticipated facility expansions, production increases,
or process modifications which will result in new, different, or
increased discharges of pollutants must be reported by submission
of a new NPDES application or, if such changes will not violate the
effluent limitations specified in this permit, by notice to the DEM
of such changes. Folluwing such notice. the permit may be modified
to specify and limit any pollutants not previously limited.
2. Facilities Operation
The permittee shall at all times maintain in good working order and
operate as efficiently as possible all treatment or control facili-
ties or systems installed or used by the permittee to achieve con-
pliance with the_teims and conditions of this permit.
3. Adverse Impact
The permittee shall take all reasonable steps to minimize any adverse
impact to navigable waters resulting from noncompliance with any
effluent limitations specified in this permit, including such accel-
erated or additional monitoring as necessary to determine the nature
and impact of the noncomplying discharge.
4. Bypassing
Any diversion from or bypass of facilities necessary to maintain com-
pliance with the terms and conditions of this permit is prohibited.
except (i) where unavoidable to prevent loss of life or severe
property damage. or (ii) where excessive storm drainage or runoff
would damage any facilities necessary for compliance with the
effluent limitations and prohibitions of this permit. The permittee
shall promptly notify the Water Quality Section of DEM in writing of
each such diversion or bypass.
5. Removed Substances
Solids, sludges, filter backwash, or other pollutants removed in the
course of treatment or control of wastewaters shall be disposed of in
a manner such as to prevent any pollutant from such material from
entering waters of the State or navigable waters of the United
States.

PART II
6. Power Failures
In order tosmaofn�his. cmance with the the permitteefshallteitherations and
prohibition permit,
a. Provide an alternative power source sufficient to operate
the wastewater control facilities;
or, if such alternative power source is not in existence,
b. Halt, reduce, or otherwise control production and/or all dis-
loss, orff iluretofathe primary sourcetofspower toesaiduwaste-
loss,
water control facilities.
B. RESPONSIBILITIES
1. Right of Entry
The permittee shall allow the Director of the Division of Environ-
mental Management, the Regional Administrator, and/or their author—
ized representatives, upon the presentations of credentials:
a. To enter upon the permittee's premises where an effluent
h any
be kto
eptiunderlocated
the terms and cconditions rrequiredds are
of thispermitand
be
b. At reasonable times to have access to and copy any records
.required to be kept under the terms and conditions of this
permit; to inspect any monitoring equipment or monitoring
method required in this permit; and to sample
y
of pollutants.
2. Transfer of Ownership or Control
This permit is not transferable. In the event of any change in con-
trol or ownership of facilities from which the authorized discharge
emanates or is contemplated, the permittee shall notify the prospec-
tive tive owner or controller by letter of the existence of this permit
and r. to mope ofothetain a letterpshall be forwarded toermit in the name of the thepDivision of
owner. A copy
Environmental Management.
3. Permit Modification
After notice and opportunity for a hearing pursuant to NCGS 143-215.1
(b)(2) and NCGS 143-215.1(e) respectively, this permit may be modi-
fied, suspended, or revoked in whole or in part during its term for
cause including, but not limited to, the following:

PART II
a. Violation of any terms or conditions of this permit;.
b. Obtaining this permit by misrepresentation or failure to
disclose fully all relevant facts; or
c. A change in any condition that requires either a temporary
or permanent reduction or elimination of the authorized
discharge.
4. Civil and Criminal Liability
Except as provided in permit conditions on "Bypassing" (Part II.
A-4) and "Power Failures (Part II, A-6), nothing in this permit
shall be construed to relieve the permittee from civil or criminal
penalties for noncompliance pursuant to NCGS 143-215.6 or Section
309 of the Federal Act, 33 USC 1319.
5. Property Rights
The issuance of this permit does not convey any property rights in
either real or personal property, or any exclusive privileges, nor
does it authorize any injury to private property or any invasion of
personal rights, nor any infringement of Federal, State, or local
laws or regulations.
6. Severability
The provisions of this permit are severable, and if any provision of
this permit, or the application of any provision of this permit to
any circumstance, is held invalid, the application of such provision
to other circumstances, and the remainder of this permit shall not
be affected thereby.
7. Expiration of Permit
Permittee is not authorized to discharge after the expiration date.
In order to receive authorization to discharge beyond the expiration
date, the permittee shall submit such information, forms, and fees
as are required by the agency authorized to issue permits no later
than 180 days prior to the expiration date. Any discharge without
a permit after the expiration will subject the permittee to enforce-
ment procedures as provided in NCGS 143-215.6 and 33 USC 1251 et seq..

i
PART III
A. PREVIOUS PERMITS
All previous State water quality permits issued to this facility,
whether for construction or operation. or discharge, are hereby
revoked by issuance of this permit. The conditions, requirements,
terms, and provisions of this permit authorizing discharge
under then
National Pollutant Discharge Elimination System govern
from this facility-
B. CONSTRUCTION
No construction of wastewater treatment facilities or additions thereto
shall be begun until Final Plans and Specifications have been submitted
roval and
to the Division of Environmental Management and written app
Authorization to Construct have been issued. If no objections to Final
Plans and Specifications have been made by the DEM after 30 days follow-
ing receipt ofbethe
considered approved andthis
construcs latter,
the plans may tion authorized
C. SPECIAL CONDITIONS
1. The Pezmittee shall be responsible for the following items regard-
ing the maintenance of the treatment system:
a. Septic tanks shall be maintained at all times to prevent
seepage of sewage or effluents to the surface of the ground.
b. Septic tanks need routine maintenance and shouldd to be checked
at least yearly to determine if solids
moved
or other maintenance performed.
C. Contents removed from septic tanks shall be discharged into
an approved sewer system, buried or plowed under at an
approved location within 24 hours, or otherwise disposed of
at a location 'and in a manner approved by the State or local
agency..
2. The eastshall
properly connect noperational
bl
ownedewatecollectionsystemwithin180daysofitsavaiability
to the site.

Date: February 12, 1990
NPDES STAFF REPORT AND RECOMMENDATIONS
County: Cabarrus
NPDES Permit No. NC 0063231
MRO No. 90-18
PART I - GENERAL INFORMATION
1. Facility and Address: Jeffery A. Gilbert Residence
2581 Essex Drive
Concord, N. C. 28025
2. Date of Investigation: February 5, 1990
3. Report Prepared By: Kim H. Colson, Environmental Engineer I
4. Persons Contacted: Carol Gilbert, Owner
Telephone Number: [phone]
5. Directions to Site: From the junction of Highway 601 Business (Union
Road) and SR 2635 (Old Airport Road) travel northeast on SR 2635
approximately 1.2 miles and turn left on Colfax Drive (No SR No.).
Travel 0.1 mile and turn left on Thompson Drive. Travel 0.3 miles and
turn right on Essex Drive. The site is on the left side of Essex Drive
after traveling approximately 0.2 miles.
6. a. The coordinates to the proposed point of effluent discharge are:
Latitude: 350 24' 11" Longitude: 800 32' 11"
b. USGS Quad No.: F16NE (see attached map)
7. Size (land available for expansion an upgrading): There is adequate
land available for expansion.
8. Topography (relationship to flood plan included): Moderate slopes,
plant does not appear to be in the flood plain.
9. Location of nearest dwelling: Two dwellings are located within 1000 feet.
10. Received stream or affected surface waters: Little Cold Water Creek
a. Classification: C
b. River Basin and Subbasin No.: Yadkin 03-07-12
C. Describe receiving stream features and pertinent downstream uses:
The 7Q10 stream flow is greater than 0.0 cfs. Discharge does not
appear to have an adverse impact on the receiving stream.
PART II - DESCRIPTION OF DISCHARGE AND TREATMENT WORKS
1. Type of wastewater: 100% Domestic
0% Industrial

r
Page Two
a. Volume of wastewater: 0.00036 MGD 0.001 Design
b. Types and quantities of industrial wastewater: N/A.
C. Prevalent toxic constituents in wastewater: N/A.
d. Pretreatment Program (POTWs only): N/A.
2. Production rates (industrial discharges only) in pounds: N/A.
3. Description of industrial process (for industries only) and
applicable CFR Part and Subpart: N/A.
4. Type of treatment (specify whether proposed or existing): Treatment
consists of septic tank and recirculating sand filter.
5. Sludge handling and disposal scheme: Septic tank hauler when necessary.
At this point in time sludge disposal has not been necessary.
6. Treatment plant classification: I
7. SIC Code(s) 9999
Wastewater Code(s) 04
PART III —OTHER PERTINENT INFORMATION
1. Is this facility being constructed with Construction Grants Funds
(municipals only)? N/A.
2. Special monitoring requests: N/A.
3. Additional effluent limits requests: N/A.
4. Other: N/A.
PART IV - EVALUATION AND RECOMMENDATIONS
Applicant, Jeffery A. Gilbert, has applied for renewal of the permitted
discharge. The discharge is for a single family residence.
At this point in time, sewer service has not been made available. The
system appears to be adequately operated and maintained.
This Office recommends that the Permit be renewed.
7� X
Signature of report preparer
Water Quality RegiorCdl Supervisor

.)LAND 11 Ml.� CHARLOTTE 21 M1. 432'3C
ONROE 30 Ml.
1 MILE
'000 6000 7000 FEET
1 KILOMETER
1929
CY STANDARDS
RVEY
GINIA 22092
3 AVAILABLE ON REQUEST
O ��SLN I�1Z6k SITi_
F 16 NlL
N. C.
QUADRANGLE LOCATION
Revisions shown in purple and woodland compiled in
cooperation with State of North Carolina agencies from
aerial photographs taken 1984 and other sources. This
In
• • VIR INTERIO 5—GEOLOGI.aL SURVE , RESTON, GINIA-5987E
44 45-m E.
ROAD CLASSIFICATION
Primary highway, Light -duty road, hard or
hard surface . __. improved surface ...
Secondary highway,
hard surface Unimproved road
�J Interstate Route U. S. Route �� State Route
CONCORD, N. C
35080-D5-TF-024
1969
PHOTOREVISF_D 198

5TATE
RECEIVED
>� �y
VISION OF ENVIRONMENTAL YAPoASEYM
24 1990
\I\.� YOOAESVILIi `
9 State of North Carolina
. Department of Environment, Health, and Natural Resources
Division of Environmental Management
512 North Salisbury Street ® Raleigh, North Carolina 27611
1/23/90
James G. Martin, Governor
William W. Cobey, Jr., Secretary
Mr. Jeffery A. Gilbert
2581 Essex Drive
Concord, NC 28025
:ear Mr. Gilbert
R. Paul Wilms
Director
Subject: NPDES Permit Application
NPDES Permit No.NC0063231
Jeffery A. Gilbert Residence
Cabarrus
Countv
his is to acknowledge receipt of the following documents on January 23, 1990:
Application Form
Engineering Proposal (for proposed control facilities),
W/ Request for permit renewal,
Application Processing Fee of $60.00,
—_ Other ,
-e items checked below are needed before review can begin:
Application Form _,
Engineering proposal (.see attachment),
Application Processing Fee of
Delegation of Authority (see attached)
Biocide Sheet (see attached)
Other
Tf the application is not made complete within thirty (30) days, it will be
returned to you and may be resubmitted when complete.
This application has been assigned to Mack Wiggins
(919/733-5083) of our Permits Unit for review.. You will e advised ot any
comments recommendations, questions or other information necessary for the
review of the application.
? 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 applications,
please contact the review person listed above.
�Sincerely, /
Jn �I. Dale Ovet'c sh, P . E .
CC : _ 1ooreserille Rege,ria. •,ffice 1
i
Pollution Prevention Pays
P.O. Box 27687, Raleigh, North Carolina 27611.7687 Telephone [phone]
An Equal Opportunity Affinnadve Action Employer

NORTH CAROLINA DEPT. OF NATURAL RESOURCES AND CONWNITY DEVELOPMENT
ENVIRONMENTAL MANAGEMENT C"ISSION
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
APPLICATION.FOR PERMIT TO DISCHARGE - SHORT FORM G FOR
To be filed otily by services. wholesale and retail trade,
and other commercial establishments including vessels
AGENC1f
USE
AML T CATION Ma1BF p
0
101
dj�-
DATE INCLIYIn
()
1 01 r
=
REAR 10. DAY
Do not attempt to complete this form Without reading the accompanying instructions � ��'�% 0
Please print or type °2
1. Now., address, and telephone number of facility producing discharge
A. Name Jeff Gilbert
S. Street address 2581 Essex Drive
C. City Concord 0. State NC
E. County Caharrna F. dip 75
G. Telephone No. 704 786-4596 (1r
Are.
Code
41' ti
2. sic
(Leave blank)
1
3. Number of employees
{. Nature of business 3 Bedroom House
5. (a) Check here if discharge occurs all year:, or
(b) Check the month(s) discharge occurs:
1,0January 2.0Fab ruary 3.ONero 6.0Apri1 5.0NAY
6. 0 June 7. 0 July 8.0 August 9.0 September 10.c October
11. 0 November 12.0 December
(c) How many days per week:
1.01 2.0 2-3 3.0 4-5 4A6-7
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
0.1.999
1000-4999
S000-S'999
10,000.
50,000
None
30-
65-
95.
operating day
69."9
ormore
10.1-
29.9
64.9
94.9
LOG
(1)
(2)
(3)
(4).
(S)
(6)
(8)
(9)
(10)
A. Sanitary, daily
360 GAL
fpER
average
DAY
x
B. Cooling water, etc.,
daily average
C. Other diseharge(s),
,
daily average;
Specify
D. Maximum per operat.
ing day for comctnea
discharge (all types)

7. if any of the types of caste identified in Rota 6, either Mated or 01-
treated. are discharged to places other than surface waters, check 10low
as applicable.
Haste water is discharged to:
0.1-!99
(1)
1000499!
(2)
9000-9999
(3)
10.0064,."t
(dl
50.000 or more
M
A. MWILipal cewl-r Systeaa
It. 11111i1.1111'IM1111i w►•I1
C. Sept if- tank
360 GAL.
D. Evaporation lagoon or pond
L othE . sspeciiy:
S. Nu4n r of separate discharge points:
AM 1 ®. o2-3 t.o 4-5 0.o 6 or More
9. Nave of receiving water or waters T i ttl P C r)1 ri Water C.—Ir
10. Does your discharge contain or is it possible for your discharge to contain
me or more of the following substances as a result of your operations.
activities, or processes: ammonia, Cyanide, aluminum, beryllium, Cadmium,
chromium. copper, lead, wmrcury, nickel, selenium, =inc. /hsaels. Oil amd
grease, and chlorine (residual).
A. 0 yes
1 certify that I in familiar with the information Contained in the application and
that to the best of my knowledge and belief such information Is true. COMPlette and
accurate.
Jeff Gilbert
Printed Nave of Person Signing
Home Owner
'North Carolina General Statute 143-215.6(b)(2) provides that: Any perm who knovinitly mars'
,any false statement representation, or certification = any app1icat10Rv*record9 report, p:z
or other document files ter required to be tsaintainod under Article 21 or regulations of the
Environmental MU=9enent Commission izplsmsn;UM that Article, or who falsifies, tastpers U' t
ur lcnwly renders inaccurate any'recordfn= or tsoonitorin idea or method requirad to be
t-Yerated or maintained under ATtiele 21-oir. regulatimtis of the Enviroaaautal Manasement Cot~_
imp'_e=entfng that Article, &hall •ba TtLiity -of i sisdameanor punishable by a •fins not to exce
510,non, or by imprisonment not to exceed six months, or by both. (18 U.S.C. Section 1001 p-
A punishment by a fine of"stot more than $10.000 or islprisament not tore than 5 years. or br.-
`„r a airnilar o!fenae.)
{