NCG551169_Regional Office Historical File Pre 2018 (2)

Environmental
Quality
March 6, 2018
Mr. Jerry Wayne Buller & Mrs. Pamela Buller or the current resident
110 Hull Drive
Dallas, NC 28034
ROY COOPER
F
�'LEHAEL
Govemor
S. REGAN
Secretary
LINDA CULPEPPER
Interim Director
Subject: Compliance Evaluation Inspection
110 Hull Drive
Certificate of Coverage No. NCG551169
Gaston County
Dear Mr. Jerry Wayne Buller & Mrs. Pamela Buller or current tenant:
Please be advised that NCDEQ inspector will be coming to, inspect subject permit on
March 27, 2018 at about 11 AM. Your presence during the inspection is advised to discuss
compliance with the conditions listed in subject permit.
If you wish to reschedule or have any questions, please contact Ori Tuvia at (704) 235-
2190, or via email at ori.tuviaancdenr.gov
Sincerely,
Ori Tuvia, Environmental Engineer
Mooresville Regional Office
Division of Water Resources, DEQ
CG) ne-1--
��-�6�-to61
Mooresville Regional Office
Location: 610 East Center Ave., Suite 301 Mooresville, NC 28115
Phone: [phone] Fax: [phone] Customer Service: 1-877-623-6748
Intomct• unenu nnniatamnalifv nrn

,� ® Full Service Analytical &
R S M Ir Environmental Solutions
Wilce Martin
Wilce Martin
110 Hull Dr.
Dallas, NC 28034
NC Certification No. 402
SC Certification No. 99012
NC Drinking Water Cert No. 37735
VA Certification No. 460211
DoD ELAP: L-A-B Accredited Certificate No. L2307
ISO/IEC 17025: L-A-B Accredited Certificate No. L2307
Project: Septic Tank
Project No.: Gen. Permit NCG550000
Lab Submittal Date: 01/12/2016
Prism Work Order: 6010188
Case Narrative
01 /21/2016
This data package contains the analytical results for the project identified above and includes a Case Narrative, Sample
Results and Chain of Custody. Unless otherwise noted, all samples were received in acceptable condition and processed
according to the referenced methods.
Data qualifiers are Flagged individually on each sample. A key reference for the data qualifiers appears at the end of this case
narrative.
Please call if you have any questions relating to this analytical report.
Respectfully,
PRISM LABORATORIES, INC.
i
Terri W. Cole
Project Manager
Data Qualifiers Key Reference:
Reviewed By Terri W. Cole
Project Manager
BRL Below Reporting Limit
MDL Method Detection Limit
RPD Relative Percent Difference
* Results reported to the reporting limit. All other results are reported to the MDL with values between MDL and
reporting limit indicated with a J.
This report should not be reproduced, except in its entirety, without the written consent of Prism Laboratories, Inc.
449 Springbrook Road - P.O. Box 240543 - Charlotte, NC 28224-0643
Phone: [phone] - Toll Free Number: 1-800/529-6364 - Fax: [phone]

Sample Receipt Summary
.LAS,
Full-Service Analytical& '
ISM' I_ EriWronmentof Solutions 01/21/2016
_ lA0CRAMRIE&ING.
Prism Work Order: 6010188
Client Sample ID Lab Sample ID Matrix Date Sampled Date Received
001 6010188-01 Water 01/12/16 01/12/16
Samples were received in good condition at 0.9 degrees C unless otherwise noted.
This report should not be reproduced, except in its entirety, without the written consent of Prism Laboratories, Inc.
449 Springbrook Road - P.O. Box 240543 - Charlotte, NC 28224-0543
Phone: [phone] - Toll Free Number: 1.800/629.6364 - Fax: [phone]

'a
,is 1�1 ,h\ Full Service Analytical R � R Environmental Solutions
LABORA"fOH�$ING - - ..
Wilce Martin Project: Septic Tank
Attn: Wilce Martin
110 Hull Dr. Project No.: Gen. Permit
Dallas, NC 28034 NCG550000
Laboratory Report
01/21/2016
Prism Work Order: 6010188
Field Data
Laboratory ID Client ID Field Parameter Result
6010188-01 001
Residual Chlorine (mg/L)
This report should not be reproduced, except in its entirety, without the written consent of Prism Laboratories, Inc.
449 Springbrook Road - P.O. Box 240643 - Charlotte, NC 28224-0643
Phone: [phone] - Toll Free Number: 1-800/529-6364 - Fax: [phone]
0.15

EA Full -Service Analytical $
Environmental Solutions
CAROM IE INa. F S
Laboratory Report
01/21/2016
Wilce Martin Project: Septic Tank Client Sample ID: 001
Attn: Wilce Martin Prism Sample ID: 6010188-01
110 Hull Dr. Project No.: Gen. Permit NCG550000 Prism Work Order: 6010188 .
Dallas, NC 28034 Sample Matrix: Water Time Collected: 01/12/16 11:15
Time Submitted: 01/12/16 15:15
Parameter Result Units Report MDL Dilution Method Analysis Analyst Batch
Limit Factor Date/Time ID
General Chemistry Parameters
Biochemical Oxygen Demand BRL mg/L 3.4 1 'SM5210 B 1/13/16 13:19 EGC P6A0246
Total Suspended Solids 14 mg/L 2.6 0.80 1 'SM 2540 D 1/13116 13:35 EGC PSA0174
Microbiological Parameters
Fecal Coliforms . BRL CFU/100 ml 2 1 "SM9222 D 1/12/16 15:50 EGC P6A0203
This report should not be reproduced, except in its entirety, without the written consent of Prism Laboratories, Inc.
449 Springbrook Road - P.O. Box 240543 - Charlotte, NC 28224-0543
Phone: [phone] - Toll Free Number: 1-800/529-6364 - Fax: [phone]

"Y!
•rrr.
rPISM
Full -Service Analytical &
Environmental Solutions
ABORATORIES. INC.
449 Springbrook Road • Charlotte, NC 28217
Phone [phone] Fax: 704/5f��
Client Company Name:dX �'r7
Report To/Contact Name:
Rep ng A ress: //
2_
CHA114 OF CUSTODY RECORD
PAGE I OF / QUOTE # TO ENSURE PROPER BILLING;
Project Name:
Short Hold Analysis: /(Yes) (No UST Project: (Yes) (NO)
*Please ATTACH any project specific reporting (QC LEVEL 1 II III IV)
provisions and/or QC Requirements
Invoice To:
Address:
Phone Fax (Yes) (No): Purchase Order No./Billing Reference
'yD
TO BE FILLED IN BY CLIENT/SAMPLING PERSONNEL/
Email Address: 4 Requested Due Date El1 Day El2 Days El3 Days ❑ 4 Days ❑ 5 Days
Certification: NELAC DOD
FL NC
EDD Type: PDF_Excel "Working Days" ❑ 6-9 Days ❑ Standard 10 days ❑ RushMust Be
Ap Work
_Other
re
Site Location Name: Samples received after 14:00 will be processed next business day.
Sced OTH�W
N
Site Location Physical Address: Turnaround time is based on business days, excluding weekends and holidays.
Water Chlorinated: YES_ NO
(SEE RENDERERSE FOR TERMS & CONDITIONS REGARDING D BY PRISM LABORATORIES, INC. TO CLIENT) SERVICES
Sample Upon
Iced U on Collection: YES
NO
TIME
MATRIX
SAMPLE CONTAINER
ANALYSIS
JZEQUESTED
PRISM
CLIENT
SAMPLE DESCRIPTION
DATE
COLLECTED
COLLECTED
MILITARY
(SOIL,
WATER OR
PRESERVA-
TIVES
� r
REMARKS
LAB
ID NO.
*TYPE
HOURS
SLUDGE)
SEE BELOW
NO.
SIZE
001
/ i
J►"'
gb
25-7>
I AAA
Sampler's Signature Sampled By (Print Name) Affiliation
Upon relinquishing, this Chain of Cus ody is your authorization for Prism to proceed with the analyses as requested above. Any changes must be
•
submitted In writing to the Prism Project Manager. There will be charges for any changes after analyses have been initialized.
Relin Is a y: (Signature ceived By: (Signature) Date
Military/Hours Additional Comments:
Site Arri+ial'Time-
Relinqul By: (Signature) Received By: (Signature) Date
SitDepatttite
Relinquished By: (Signature) e ' ed For Pdsm Laboratori y: Date
Field:Tecti`,Fee
vvw�. = 1 _\2_1In
15'I�
:: :::........;;.::.;:::,
e.
Method of Shipment: NOTE: ALL SAMPLE COOLERS SHOULD BE TAPED SHUT WITH CUSTODY SEALS FOR TRANSPORTATION TO THE LABORATORY. CDC Group No.
SAMPLES ARE NOT ACCEPTED AND VERIFIED AGAINST COC UNTIL RECEIVED AT THE LABORATORY.
Cl Fed Ex ❑ UPS ❑ Hand -delivered W. Field Service ❑ Other
NPDES: UST: G NDWATER: DRINKING WATER: SOLID WASTE: RCRA: CERCLA LANDFILL OTHER:
'
oNC ❑ SCI o NC ❑ SC o NC ❑ SC I ❑ NC ❑ SC ❑ NC ❑ SC ❑ NC ❑ SC I El NC ❑ SC o NC ❑ SC I o NC ❑ SC
TERMS & CONDITIONS
T. ..: *CONTAINER TYPE CODES: A = Amber C = Clear G= Glass P = Plastic; TL = Teflon -Lined Cap VOA = Volatile Organics Analysis (Zero Head Space) notr._+nt n+

PAT MCCRORY
Govenlor
DONALD R. VAN DER VAART
Secrelay
Water Resources S. JAY ZIMMERMAN
ENVIRONMENTAL QUALITY
Director
December 1, 2016 RECEIVED/NCDENR/DWR
Mr. Jerry Wayne Buller & Mrs. Pamela A. Buller DEC m 6 2016
110 Hull Drive WQROS
Dallas, NC 28034 PJIOORESVILLE REGIONAL OFFICE
Subject: General Permit NCG550000
110 Hull Drive
Certificate of Coverage NCG551169
Gaston County
Dear Permittee:
The Division has received and approved your request to transfer ownership of the subject Certificate
of Coverage (CoC) under General Permit NCG550000. As a result, the Division hereby reissues NCG551169.
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 any other State, Federal, or Local
governmental permit ,that may be required. If you have any questions concerning the requirements;of the
General Permit, please contact Brianna Young of the NPDES staff [919-807-6388 or
brianna. young@ncdenr. gov] . .
S ncerely,
for S. Jay Zimmerman,
Director, Division of Water Resources
cc: Mooresv_ille_Regiona_1Office
NPDES File
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh, NC 27699-1617
919 807 6300 919-807-6389 FAX
https:lldeq.nc.gov/aboutldivisions/water-resources/water-resources-pern itslwastewater-branchlnpdes-wastewater-permits

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
GENERAL PERMIT NCG550000
CERTIFICATE OF COVERAGE NCG551169
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,
Jerry Wayne Buller & Pamela A. Buller
is hereby authorized to discharge <1000 gallons per day of domestic wastewater from a
facility located at I -
110 Hull Drive
Dallas
Gaston County
to receiving waters designated as Little Long Creek, a class C stream in subbasin 03-08-36 of the
Catawba 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 takes_ effect December 1, 2016.
This Certificate of Coverage shall remain valid for the duration of the General Permit.
Signed this day December 1, 2016.
F
i
for, Zimmerman, P.G.
erector, Division of Water Resources
By Authority. of the Environmental Management Commission

LENorth- Carolina Department of Environmental Qua it
p Y
Pat McCrory Donald van der Vaart
Govemor Secretary
October 27, 2015
Mr. Wilce Martin
3966 Fairview Dr.
Maiden, NC 280
Subject: Compliance Evaluation
NPDES Permit No. NCG551169
Gaston County
Dear Mr. Martin:
Enclosed is a copy of the Compliance Evaluation Inspection (CEI), for the inspection conducted at the
subject facility on September 30, 2015, by Ms. Barbara Sifford with this Office. The system appeared to be
operational and maintained although no discharge was occurring at the time of this inspection since the
residence is vacant.
Analytical data for compliance monitoring for the treatment system has not been evaluated since there is
no discharge from the system. This should be completed annually and list of contract labs is enclosed with this
inspection. The septic tank is to be pumped prior to the sale of the property.
Chlorine tablets for wastewater treatment (not pool tablets) can be purchased from USA Blue Book on
line or McCall Brothers plumbing supply in Charlotte. You can download a copy of the NCG550000 permit
from our web site, htt-p://Dortal.ncdenr.org/web/Wq.
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].
Sincerely,
zat/w(4 's ct
Barbara Sifford
Technical Consultant
Water Quality Regional Operations
Mooresville Regional Office NCDEQ
Enclosure —Inspection report
Commercial contract labs
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
` brie
NI'M-Uxohna
An Equal Opportunity 1 Affirmative Action Employer— 50% Recycled/10% Post Consumer paper

North Carolina Department of Environmental Quality
Pat McCrory Donald van der Vaart
Govemor Secretary
October 27, 2015
Mr. Wilce Martin
3966 Fairview Dr.
Maiden, NC 280
Subject: Compliance Evaluation
NPDES Permit No. NCG551169
Gaston County
Dear Mr. Martin:
Enclosed is a copy of the Compliance Evaluation Inspection (CEI) for the inspection conducted at the
subject facility on September 30, 2015, by Ms. Barbara Sifford with this Office. The system appeared to be
operational and maintained although no discharge was occurring at the time of this inspection since the
residence is vacant.
Analytical data for compliance monitoring for the treatment system has not been evaluated since there is
no discharge from the system. This should be completed annually and list of contract labs is enclosed with this
inspection. The septic tank is to be pumped prior to the sale of the property.
Chlorine tablets for wastewater treatment (not pool tablets) can be purchased from USA Blue Book on
line or McCall Brothers plumbing supply in Charlotte. You can download a copy of the NCG550000 permit
from our web site http://portal.ncdenr.org/web/wq.
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].
Sincerely,
Barbara Sifford
Technical Consultant
Water Quality Regional Operations
Mooresville Regional Office NCDEQ
Enclosure —Inspection report
Commercial contract labs
Mooresville Regional Office
Location: 610 East Center Ave., Suite 301 Mooresville, NC 28115
Phone: [phone] \ Fax: [phone] \ Customer Service:1-877-623-6748
Intemet: www.ncwaterquality.org
One--r-
NorthCarolina
An Equal Opportunity \ Affirmative Action Employer — 50% Recycled110% Post Consumer paper

Sifford; Barbara'
From: Wilce Martin <[e-mail]>
Sent: Tuesday, February 09, 2016 12:44 PM
To: Sifford; Barbara
Subject: FW: Lab Report 6010188
Attachments: 6010188 FINAL 0121 16 1201.pdf
Barbara:
I have attached the annual test results for 110 Hull Drive for 2016 as required by the permit for the septic tank
discharge. The house has been sold and the new owners were given the change of ownership form to send in to
you.
thanks,
Wilce
From: [e-mail]
To: [e-mail]
Subject: Lab Report 6010188
Date: Mon, 1 Feb 2016 12:30:44 -0500
Hello! Please see your lab report attached. Thanks!
3 J�'YlLtdhiG139ii[GdY10
5?rinuiksxwL - '
Terri Cole
Project Manager
Office: 704.529.6364
Fax [phone]
When You Need RESULTS .......
[e-mail]
www.prismlabs.com
449 Springbrook Rd., Charlotte, NC 28217 / Mail: P.O. Box 240543,Charlotte,NC 28224-
0543
SBA Certified Women -Owned, Small Business
1

CONFIDENTIAL & PRIVILEGED
Unless otherwise indicated or obvious from the nature of the following communication, the information contained herein is attorney -client
privileged and confidential information/work product. The communication is intended for the use of the individual or entity named above. If
the reader of this transmission is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this
communication is strictly prohibited. If you have received this communication in error or are not sure whether it is privileged, please
immediately notify us by return e-mail and destroy any copies, electronic, paper or otherwise, which you may have of this communication.

Sifford, Barbara
From: Weaver, Charles
Sent: Wednesday, September 03, 2014 9:40 AM
To: Sifford, Barbara
Subject: RE: SFR NCG551169
I can't find anything explaining why billing was suspended, either. I've turned the annual fees back on. They should
receive a bill in December.
Thanks for letting me know.
CHW
From: Sifford, Barbara
Sent: Tuesday, September 02, 2014 11:09 AM
To: Weaver, Charles
Subject: SFR NCG551169
I saw that the annual fees for this system have been waived. Any idea on why or who do I ask? There is nothing in the
file here at MRO.
Barbara Sifford - [e-mail]
Technical Consultant- Division of Water Resources
North Carolina Dept. of Environment & Natural Resources
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Ph:704.663.1699 DWQ
Direct line 704-235-2196 desk (preferred)
Fax: [phone]
E-mail correspondence to and from this address may be subject to the
North Carolina Public Records Law and may be disclosed to third parties unless the context is exempt by statute or other
regulation.

l micnaei r. tasiey, vovernor
r ? William G. Ross, Jr., Secretary ?'
>_ a North Carolina Department of Environment and Natural Resources f
O �Coleen H. Sullins, Director T %� !:
Division of Water Quality 1:
23 May 2008
Mr. Chad E. Davis
110 Hull Drive
Dallas, NC 28034-9715
Subject: Single Family Residence Wastewater Treatment
System
NPDES General Wastewater Permit No./Certificate
of Coverage NCG551169
Compliance Evaluation Inspection '
Dear Mr. Davis:
Division of Water Quality (DWQ) database records show that you currently own/operate a single
family residenc1. e (SFR) wastewater treatment and disposal system. DWQ personnel from tlie-Mooresville
Regional Office (MRO) need to conduct a comprehensive review of your system with you in order to
verifyl,that. your system is operating properly and to determine the compliance status of the system
pursuant tg,your N6G551169 permit. We anticipate such a review would take approximately one to two
hours,'prQvicled. that all needed documentation and data is readily available at the time of the site visit.
Due to the difficulties involved with catching owners at home during the. workday,.�ve w1.ould like
it
to pre -schedule this site visit with you to ensure we can meet and complete the required system' review as
expeditiously as possible. In order to facilitate this we ask that you contact Mr. Ron Boone, of our office,
at 704-663-1699, between the hours of 8AM and 4PM, Monday through Friday. Please contact Mr.
Boone within the next 10 days to identify the best possible time for an evaluator to visit your .SFR and
conduct this review with you.
Also, in the interest of conducting the most efficient evaluation possible, we ask that you have
certain items of documentation on hand at the time of the site visit. These items include the following:
Y. Permit/Certi 1cate of Coverage: Issued by DWQ,.you would have received this via regular U.S.
Postal Service mail.
2.: A' Schematic of the Treatment/Disposal System: Please have available all schematics or other
technical drawings and/or design specifications that show the complete and/or partial layout of
s; your treatment/disposal system.
3. Documentation of Analytical Monitoring: Required in Part I(A) of the general NCG550000
permit, please have available all official records of analytical monitoring conducted to date.
4. Documentation of Septic Tank Inspections/Pumping: Required in Part I(A) of the general
NCG550060 permit, please have available all records of annual septic tank inspections'and septic
tank pumping.
S. Chlorination/Dechlorination Tablets: Please have available the original containers in which
both the chlorination and dechlorination tablets were stored when you purchased them:
North Carolina Division of Water Quality Mooresville Regional Office Surface Water Protection Phone [phone] Customer Service
Internet: h2o.enr.state.nc.us 610 East Center Avenue, Suite 301 Mooresville, NC 28115 FAX [phone]
An Equal Opportunity/Affirmative Action Employer — 50% Recycled/10% Post Consumer Paper NorthCarolina
�Naiirra!!�

23 May 2008
We appreciate your time and understanding of our mission to preserve the natural resources of our
great state and look forward to you contacting us to schedule this site visit. If for some reason you're
unable to contact us, we will make every effort to contact you to schedule the review of your_ system: If
you have questions or concerns about this letter or the required review, please contact Mr. Boone between
the hours of 8AM and 4PM, Monday through Friday at 704-663-1699. If he is not there when you call,
please leave your name and a good contact phone number and he will return your call as soon as possible.
Sincerely,
Robert B. Krebs
Surface Water Protection Section Supervisor
Division of Water Quality
Mooresville Regional Office
3

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Michael F. Easley, Governor
Wilce Martin
110 Hull Drive
.Dallas, NC 28034
Dear Permittee:
William G. Ross, Jr., Secretary
Coleen H.. Sullins, Director
January 6, 2009
Subject: Renewal of. coverage / General Permit NCG550000
110 Hull Drive
Certificate of Coverage NCG561169
Gaston County
In accordance with your renewal application [received on December 29, 20081, the Division is.
renewing Certificate of Coverage (CoC) NCG551169 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 [oi
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.
RegYonal 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 Toya
Fields [919 807-6385 or [e-mail].
Sincerely,
�l
Coleen H. Sullins
cc: Central Files
Moo a Ville Regional E)ffice-/-Surface Wate'_ r Protection
NPDES file
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
512 North Salisbury Street, Raleigh, North Carolina 27604 �T�One
Phone: [phone] / FAX [phone] / Internet: www.ncwaterquality.org 1� o h fC,yar+ ohna
An Equal Opportunity/Affirmative Action Employer- 50% Recycled/10% Post Consumer Paper��K` ����

I \
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NCG550000
CERTIFICATE OF COVERAGE NCG551169
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;
Wilce Martin
is hereby_ authorized to discharge domestic wastewater [360 GPD] from a facility located at
110 Hull Drive
Dallas
Gaston County
to receiving waters designated as Little Long Creek, a class C stream in subbasin 03-08-36 of the
Catawba 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 January 6, 2009.
This Certificate of Coverage shall expire on July 31, 2012.
Signed this day January 6, 2009.
U V1.
for Cn en H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission

Wilce B. Martin
110 Hull Drive
Dallas, NC 28034
704-675-52ai
704-675-8281 [fax]
[e-mail]
Fax
TO: Barbara Sifford From: Wilce Martin
Fax: [phone] Pages 4
Phone: Date November 12, 2008
Re:
❑ Urgent x For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle
Btu tiara.
The attached is the test results on my septic tank system.
VViilCe
T'd Xdd 13rN3SY-1 dH Wd6z�=B 800Z ZT AON

Y
:_� : PRISM
LABORATORIES, INC.
Date: 11106/08
Company: Wilce Martin
Contact: Wilce Martin
Address: 110 Hall Dr.
Dallas, NC 28034
Client Project ID:
Prism COC Group No:
Collection Date(s):
Lab Submittal Date(s):
Case Narrative
Septic Tank
G1008683
10/22108
10/22108
This data package contains the analytical results for the project identified above and includes a Case Narrative and Laboratory Report totaling 2
pages."A ctiain=of custody is also attabhed for the saittples'submitted4o Prism,far-thisprojecL.
Data qualifiers are flagged individually on each sample. A key reference for the data qualifiers appears at the end of this case narrative. Quality
control statements and/or sample specific remarks are included in the sample comments section of the laboratory report for each sample
affected.
Semi Volatile Analysis
NA
Volatile Analysis
NA
Metals Analysis
NA i
Analysis Mote for 035533 Duplicate BOD-5: RPD value outside the control limits.
Analysis Note for Q86533 LCS BOD-5: GGA result (160 mg/1) Is less than the control limit (167.5-228,5 mgll). Result should be
considero an estimate with possible low bias.
Please se'Ireport for comments.
Please call if you have any questions relating to this analytical report.
Date Reviewed by: Pecav Kendall _. -_.._. _ Project Manager: Terri ole
Signature: _ _ _ Signature: __
Review Date: 11/06/08 _ _ _ Approval Date: 1.1106108
Data Qualifiers Key Reference:
8: Compound also detected in the method blank.
ff: Result outside of the QC limits.
DO: Compound diluted out,
E: Estimated concentration, calibration range exceeded.
J: The analyte was positively identified but the value is estimated below the reporting limit.
H: Estimated concentration with a high bias.
L: Estimated concentration with a low bias.
M: A matrix effect is present
Notes: This report should not be reproduced, except in its entirety, without the writtten consent of Prism Laboratories, Inc. The results in this
report relate only to the samples submitted for analysis.
449 Springbrook Road, P.0, Box 240543, Charlotte NC 28224-0403
Phone: [phone] Toll Free:8001529-6364 Fax; 7041525-0409
z•d Xd3 13rN3SU1 dH Wd62r8 800Z ZT AOW

s NC Certification No_ 402
SC Certification No. 99012
' NC Drinking Water Cert. No. 37735
F.K Service A-lylicel S Emironmc.Rel Sdnlona
Wilce Martin Project ID: Septic Tank
Attn: Wilce Martin Sample Matrix: Water
110 Hull Dr.
Dallas, NC 28034
Laboratory Report
11/06/08
Cllent Sample ID: Tank
Prism Sample ID: 228499
COC Group: G1008683
Time Collected: 10/22,108 13:30
Time Submitted: 10/22/08 15:00
Parameter
Result Units Report
MDL Dilution Method
Analysis Analyst Batch
- -
_ Limit _._
_ .... Factor
DateMme ID
Biochemical Oxvnen Demand
BOD-5
BRL mg/L 3.6
3.5 1 SM5210 B
10/23/08 15:56 kpowers Q36533
*Analysis Note for BOD-5: GGA result (160 mg/1) is less than the control limit (167.5-228.5
mg/1). Result should be
considered an estimate
with possible low bias,
Fecal Coliform by Membrane Filter
Fecal Coliform BRL CFU/100 ml 2.0 2.0 1 SM9222 D 10/22/08 15:50 kpowers Q363B6
Residual Chlorine, DPD Colorimetric Method
Residual Chlorine 16 }ig/L
Total Suspended Solids
Total Suspended Solids 4.4 mg/L
10 7.0 1 SM4500-CI G 10/22/08 13:30 dmace
2.0 1.6 1 SM2540 D 10/28/08 13:00 *knight
Sample Comment(s):
BRL = Below Reporting Limit
Values are reported down to the reporting limit only No J-Flags applied.
The results in this report mfete only to the samples submitted for analysis and meet state certiflca66n requirements other than
NELAC certification except for those instances indicared in the case narrative and/or test comments.
All results are reported on a wet-welght basis
Angela D. Overcash, V.P. Laboratory Services
This report should not be reproduced, except in its entirety, without the written consent of Prism Laboratories, Inc.
449 apringbrook Road - P.O. Box 240543 - Charlotte, NC 28224-0543
Phone: [phone] - Toll Free Number: 7.8001529-6364 - Fax: 704t525-0409
Q35496
Page 1 of 1
6-of XUA 13CN3Sd-I dH Wd6z s e 8002 21 ^ON

CHAIN OF CUSTODY RECORD
PAGE' _!�_ OI' L-- QUOTA; y TO ENSURE PROPER BILLING:
AA SerAcoAnaytfcal 6 Enviroml>srMel8dlidonet ;1 Project Name:
"9 Sprilr4brook Road' RO. Box 24050 OhMat* NC fb!-043 .Short Hold Analysis: (Yes) (No) UST Project: (Yes), (No)
Phone:7041M-M • Fox:704/6Q6-D409
—Ghent. Cotnpan�Nam� ��� �� L � � 'Pl�se ATTACH any project speorfio reporting (QC LEVEL I II III N)
provlaions and/or QC Requirements
Report To/Contact Name: InvOceTo:
Reporting Addre", Address'
IN
Phone: Fax (Y®S) (No): __ purchasg Order No./Billing Reference TO BE FILLED IN BY CLIENT/SAMPLING PERSONNEL
Emall (Yes) jNo) Email Address Requested Due Date 01 Day 0 2-Days C1 3 Days ❑ 4 Days Q 5 Days Certification: NELAC USAGE FL NC_
EDD hype: f?DF—Excel Other �Vorking Days O 6 8 Days 0 Standard 10 days O Rush pomedust Be SC! OTHER
Site Location Name: Samples received attar 1ii:00 will be processed next business day.
Site Location Physical Address: Turnaround time is based on business days, excluding weekends and holidays. Water Chlorinated: YES/No—
r) BYPR1SMnlms&ooNNRIES S REG RDIN1ISERVICES Sample toed Upon Collection: YES/ NO_
TIME MATRIX • SAMPLE CONTAINER ANALYSES R9QUESTED PRIAM
CLIENT DATE COL.ECTED ' i (Solt.'' PRESERVA- REMARKS LAB
IE
FSAMPLE DESCRIPTION COLLECTED MILITARY LUD((tER SEE E OW NO. SIZE TNES ��, �t ID N0.
HOURS \ (�
I
Sampler's'Signatu Sampled
Upon relinquishi g, this of to s � e th II be
submitted in wri Prism j
agnqulshed By: (Signature) .. a<
Rellnqulehed By: (Signature) I R'
PrIS61 to
113
with the analyses as requested above- Any changes must be
nges attar analyses have been initialized.
UNTIL RECEIVED AT THE LABORATORY.
Date
❑ Fed E, 17 UPS ❑ Flanddal"rvered Priam Fleld Eemoe (Totter
NG
❑ NC O SC ❑ NC ❑ $C 4 NC ❑SCAR ❑ NCKID SLATER: I SOLID NC ❑ SC - I ❑Q NNC 'O A LANDFILL
SC OO NC L 0 SC I
O NC 0 SC I ❑❑ NC Q SC
❑— -_...1— In
_ - .. ... ❑ .+ n,_-_ n �ni.....Q. T, — Tnflnn_1 Inor1 r�on tmA =volatile OroanlC9 Analysis (Zero Head SDace)
Additional Comments:
SEE REVERSE FOR
TERMS & CONDITIONS
n0Ir]IAIAI
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0
DO
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a
3

II.
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
I. Please enter the permit number_ for which the change is requested.
NPDES Permit (or) Certificate of Coverage
N. G 1 '0 1 0 N 10 10 1 5' 1 5 1 1 11 6 9
Permit status prior to status change.
a. Permit issued to (company name):
b. Person legally responsible for permit: ' Chad
Chad E. Davis
E Davis
First MI Last
Owner
Title
110 Hull Drive
Permit Holder Mailing Address
Dallas NC 28034
City State Zip-
(?) ( )
Phone Fax
c. Facility name (discharge):
d. Facility address: 110 Hull Drive
Address
Dallas NC 28034
City State Zip
e.. Facility contact person: Chad E. Davis (?)
First / MI / Last Phone
Please provide the following for the requested change (revised permit):
a. Request for change is a result of: ® Change in ownership of the facility
® Name change of the facility or owner
If other please explain:
b.
Permit issued to (company name):
Wilce B. Martin
c.
Person legally responsible for permit:
Wilce
B Martin
First
MI Last
Owner
Title
110 Hull Drive
Permit Holder Mailing Address
Dallas
NC 28034
City
State Zip
[phone]
[e-mail]
Phone
E-mail Address
d.
Facility name (discharge):
Martin Family Residence
e.
Facility address:
110 Hull Drive
Address
Dallas
NC 28034
City
State Zip
f.
Facility contact person:
Wilce
B. Martin
First
MI Last
[phone]
[e-mail]
Phone
E-mail Address
Revised 812008

PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Permit contact information (if different from the person legally responsible for the permit)
Permit contact: N/A
First MI Last
Title
Mailing Address
City State Zip
Phone E-mail Address
V. Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
® Yes
❑ No (please explain) Strictly domestic waste no industrial activity.
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both name change and/or ownership change
requests.
❑ Legal documentation of the transfer of ownership (such as relevant pages of a contract deed,
or a bill of sale) is required for an ownership change request. Articles of incorporation are
not sufficient for an ownership change.
The certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
I, Wilce B. Martin, attest that this application for a name/ownership change has been reviewed and is
accurate and complete to the best of my knowledge. I understand that if all required parts of this
application are not completed and that.if all required supporting information is not included, this application
package will be returned as incomplete.
Signature Date
APPLICANT CERTIFICATION
I, Wilce B. Martin, attest that this application for a name/ownership change has been reviewed and is
accurate and complete to the best of my knowledge. I understand that if all required parts of this
application are not completed and that if all required supporting information is not included, this application
package will be returned as incomplete.
Signature
Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Revised 7/2008

11 ( l i � e
i
g PRISM
€^==i LABORATDRIES,MC.
Date: 11106/08
Company: Wilce Martin
Contact: Wilce Martin
Address: 110 Hull Dr.
Dallas, NC 28034/
Client Project ID:
Prism COC Group No:
Collection Date(s):
Lab Submittal Date(s):
Case Narrative
Septic Tank
G1008683
10/22108
10/22/08
This data package contains the analytical results for the project identified above and includes a Case Narrative and Laboratory Report totaling 2
pages.'A chain -of -custody is also attabhed for the samples"submitted-to Prism. for this -project:
Data qualifiers are flagged individually on each sample. A key reference for the data qualifiers appears at the end of this case narrative. Quality
control statements arid/or sample specific remarks are included in the sample comments section of the laboratory report for each sample
affected.
Semi Volatile Analysis
NA
Volatile Analysis
NA
Metals Analysis
NA
,ab and Micro Analysis
Analysis �ote for 036533 Duplicate BOD-5: RPD value outside the control limits.
Analysis �otefor Q36533 LCS BOD-5: GGA result (160 mg/l) Is less than the control limit (167.5-22B.5 mg11). Result should be
considerod an estimate with possible low bias,
Please set report for comments.
Please call if you have any questions relating to this analytical report.
Date Reviewed by: Peggy Kendall _ _ _ Project Manager: T*,ole
Signature: —.Cz_ Signature: _
Review Date: _ 11/06/08 _ Approval Date: _ 11106/08
Data Qualifiers Key Reference:
B: Compound also detected in the method blank.
#: Result outside of the OC limits,
DO: Compound diluted out.
E: Estimated concentration, calibration range exceeded.
J: The analyte was positively identified but the value is estimated below the reporting limit.
H: Estimated concentraton with a high bias.
L: Estimated concentration with a low bias.
M: A matrix effect is present
Notes: This report should not be reproduced, except in its entirety, without the writften consent of Prism Laboratories,`Inc. The results in this
report relate only to the samples submitted for analysis.
449 Springbrook Road, P,O, Box 240543. Charlotte NC 28224-0403
Phone: [phone] Toll Free: 8001529.6364 Fax: [phone]
Z'd Xd3 13C213Sd1 dH WdGZ=e BOOZ ZT AOW

W
NC Certification No. 402
SC Certification No. 99012
NC Drinking Water Cart. No. 3T735
.Fuu serve Aneiruoei a Emi--dW sa,da
Wilce Martin Project 1D: Septic Tank
Attn: Wilce Martin Sample Matrix: Water
110 Hull Dr.
Dallas, NC 28034
Laboratory Report
11/06/08
Cl lent Sample ID: Tank
Prism Sample ID:
228499
COC Group:
G1008683
Time Collected:
10/22108 13:30
Time Submitted:
10/22/08 15:00
Parameter
Result Units Report
MDL Dilution Method
Analysis Analyst Batch
-
_ Limit_
.... Factor
DateMme ID
Biochemical Oxvaen Demand-
BOD-5
BRL mg/L 3.6
3.6 1 SM5210 B
10/23/08 15:56 kpowen: Q36533
* Analysis Note for BOD-5: GGA result (160 mg/1) is less than the control limit (167.5-228-5
mg/1). Result should be
considered an estimate
with possible low bias.
Fecar Coliform by Membrane Filter
Fecal Coliform BRL CFU/100 ml 2.0 2.0 1 SM9222 D 10/22/08 15:50 kp"ers Q363B6
Residual Chlorine, DPD Colorimetric Method
Residual Chlorine 16 pglL 10 7.0 1 SM4500-CI G 10/22/08 13:30 dmace
Total Suspended Solids
Total Suspended Solids 4.4 mg/L 2.0 1.6 1 SM2540 D 10/28/08 13:00 wknight Q35496
Sample Comment(s):
BRL = Below Reporting Limit
Values are reported down to the reporting limit only. No J-Flags applied.
The results in this report relate only to the samples submitted for analysis and meet state certification requirements other than
NELAC certification except for those instances indicated in the case narrative and/or test comments.
All results are reported on a wet -weight basis
Angela D. Overcash, V.P. Laboratory Services
This report should not be reproduced, except in its entirety, without the written consent of Prism Laboratories, Inc.
449 5pringbrook Road - P.O. Box 240543 - Charlotte, NC 28224-0543
Phone: [phone] - toll Free Number: 1-8001529-6364 - Fax: [phone] Page 1 of 1
£ - d XFJ3 13CN3SY1 dH WdGZ =: B 8002 Z T now

CHAIN OF" CUSTODY RECORD
-• PACE a'�—• aV y TO �EURi PROPER WILLING:
PW Servic0 Ana"cW 6 Em"Mftr* aelllli0ritl I Project Name:
449 Sprb*h-ook Road • PLO. Box 240M • Oherieft NC ft*.Q649 .Short gold Analysis: (Yes) (No) UST Project: (Yes)" (No)
Phone:[phone] • Fex;7 ^ P ,y4
—�ignt.Gompany-Name +�1, [k.', � *Please ATTACH any proJectspeasfic reporting (QC LEVEL 111111 11r) provisions and/or QC Requirements
Report To/Contact Name: Invoice To:
Reporting Address: Address
Phone; Fax (Yes) (No):
r purchase Order NnAilling Reference
TO BE FILLED IN BY CLIENT/SAMPLING PERSONNEL
FL NC--,)—
Email (Yes) (No) Email Address
Requesiod Due Date ❑ 1 Day 0 2 Days ❑ 3 Days 0 4 Days 0 5 Days
Certification: NELAC USACE
EDD Type: PDF—Excel Other
"Working Days" 0 6-9 Daya O Standard 10 days ❑ Pro Ash pprovedrk M�t Be
'
SC` OTHER' N/A
.�✓
Site Location Name:
)n
.
Samples received after 16:00 will be processed next business day.
and holidays.
Water Chlorinated: YES/ NO
Site Location Physical Addrt9ss:
Turnaround
time is based on business days, excluding Weekends
(68E Rh SERVICES
Sample Iced Upon Collection: Y ES/ NO
ED BY PAtsnARl nBORATORIEB INC, TO CUA NTj
TIME
;. MATRIX •
. SAMPLE CONTAINER
ANALYSES R§QUESTED
PRISM
IENT'
FSAMPLE
DATE
COLLECTED
(SOIL;'
TNES
PRESERVA•Z&A
REMARKS
LA9
ID NO.
rtYPE
ESCRIPTION
COLLECTED
'MILITARY
HOUR$
WATER OR
�SLUDQE)
'SEEBELo
F N0.
SIZE
0
Upon
this Zt246 of
—lap— Y. ta�ynew�a�
n for Prlsch to I
be ohargeafor
Rellnqulshed By: (Signature) Received By
Reiinquiehed re Ra ' ' d Fp
Me RS T sH cuSTc
SAMPL E A MDANOVERIFIED'AGAIN UNTILR
❑ Fed a CJ UPS ❑ Hand.deirvered Pd- Fla'
NPDES: UST: GROU DWA
❑ NO 0 SCI 0 NO 0 SC I 0 NC ❑ SC
Lvcl S
A ! Y A l Affiliation
With the analyses as requested above. Any changes must be
nges after analyses have been initialized._
LABORATORY,
LANDFILL
ER,. DORNICKI O SCATER. I a NC ❑SCE I ❑ NC 0 SC O NC L 0 SC I OO NC 0 SC OQ N O SC
0 Q. Tk - TMInn-1 1nu11 rtmh V0A = Volatile OrOanics Analysis (Zero Head SDace)
Additional Comments:
SEE REVERSE FOR
TERMS & CONDITIONS
n13If-IAIAI
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3

Wlae B. Martin
110 Hull Drive
Dallas, NC 28034
7u�i-o7:sb281
704-675-8281 [fax]
[e-mail]
FcAg3x
To: Barbara SifPord
From: Wilce Martin
Fax: [phone] Pages 4
PhorKn Date November 12, 2008
Re:
❑ Urgent x For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle
oar i�ai e7:
The attached is the test results on my septic tank system.
11VIIce
I -d Xdd 13rN3SY1 dH Wd62:8 8000 i3I r%oW

w A TE9Q
Michael F. Easley, Governor
�OF
(�
William G. Ross Jr., Secretary
\�
Cq
North Carolina Department of Environment and Natural Resources
p �
Coleen H. Sullins, Director
Division of Water Quality
September 24, 2008
Mr. Wilce Martin
110 Hull St.
Dallas, NC 280349
Subject: Martin Family Residence
COC No. NCG551169
Gaston County
Dear Mr. Martin:
Enclosed is a copy of the Compliance Evaluation Inspection (CEI) for the
inspection conducted at the subject facility on June 25, 2008, by Ms. Barbara Sifford with
this Office. Thank you for your assistance and cooperation during the inspection. The
system appeared to be in good operational condition. However several deficiencies need
to be corrected.
1. Renew the permit, change owner name and pay annual fees that are due.
2. Perform analytical annually. (List of contract labs included)
3. Pump tank regularly based on performance.
4. Make sure that chlorine tablets are submerged in flow for proper disinfection.
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 (704) 663-
1699,ext 2196.
Sincerely,
Az'xa'� -.
Barbara R. Sifford
Technical Support
Surface Water Protection Section
Division of Water Quality
Enclosures
Central Files
NPDES Permitting Unit
Mailing Address Phone [phone] Location One Carolina
610 East Center Avenue, Suite 301 Fax [phone] East Center Avenue, Suite 301 orthCarolin
Mooresville, NC 28115 Mooresville, North Carolina
Internet: wwwmcwateraualitv.ore Customer Service 1-877-623-6748
An Equal Opportunity/Affirmative Action Employer— 50% Recycled110% Post Consumer Paper

United States Environmental Protection Agency
Form Approved.
EPA Washington, D.C. 20460
OMB No. 2040-0057
Water Compliance Inspection Report
Approval expires 8-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction Code NPDES yr/mo/day Inspection Type Inspector Fac Type
1 I NI 2 15I 3I NCG551169 111 121 08/06/25 117 181 CI 191 SI 20III
- Remarks
211111111111111IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII6
Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 QA -- ---Reserved------------
67I 169 70131 711 I 721 NJ 73 W 74 751 I I I I I Li
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)
Chad E. Davis - Residence
03:00 PM 08/06/25
02/06/01
Exit Time/Date
Permit Expiration Date
110 Hull Dr
Dallas NC 280349715
04:00 PM 08/06/25
07/07/31
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
Other Facility Data
Wilce Martin/ORC//
Name, Address of Responsible Official/Title/Phone and Fax Number
ContactedNo
Chad E Davis,110 Hull Dr Dallas NC 280349715///
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit Operations & Maintenance Records/Reports Facility Site Review
Compliance Schedules Effluent/Receiving Waters
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
(See attachment summary)
Name(s) and Signature(s) of Inspector(s) Agency/Office/Phone and Fax Numbers Date
Barbara Sifford MRO WQ//704-663-1699 Ext.2196/
Ron Boone MRO WQ//704-663-1699 Ext.2202/
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
3I NCG551169 I11 12I 08/06/25 1
17 18ICI
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
Page # 2

Permit: NCG551169 Owner - Facility: Chad E. Davis - Residence
Inspection Date: 06/25/2008 Inspection Type: Compliance Evaluation
Compliance Schedules Yes No NA NE
Is there a compliance schedule for this facility? ■ n n n
Is the facility compliant with the permit and conditions for the review period? n ■ n n
Comment: Wilce Martin needs to renew permit and pay overdue fees. Chlorine tablets
need to be checked at minimum on -a monthly basis and the annual monitoring needs to
be completed.
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? ■ 171 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:
Permit
(If the present permit expires in 6 months or less). Has the permittee submitted a new application?
Is the facility as described in the permit?
# Are there any special conditions for the permit?
Is access to the plant site restricted to the general public?
Is the inspector granted access to all areas for inspection?
Comment: Facility was installed as described in the permit.
Record Keeping
Are records kept and maintained as required by the permit?
Is all required information readily available, complete and current?
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?
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?
Has the facility submitted its annual compliance report to users and DWQ?
Yes
No
NA
NE
■nnn
n■nn
n■nn
nn■n
nn■n
n
n
n
n
n
n
nn■n
nn■n
Page # 3

Permit: NCG551169 Owner - Facility: Chad E. Davis - Residence
Inspection Date: 06/25/2008 Inspection Type: Compliance Evaluation
Record Keeping
Yes No NA NE
(If the facility is = or > 5 MGD permitted flow) Do they operate 24/7 with a certified operator on each shift?
n n n n
Is the ORC visitation log available and current?
n n ■ n
Is the ORC certified at grade equal to or higher than the facility classification?
n n ■ n
Is the backup operator certified at one grade less or greater than the facility classification?
❑ n ■ fl
Is a copy of the current NPDES permit available on site?
n ■ n n
Facility has copy of previous year's Annual Report on file for review?
n n ■ n
Comment: The new owner was provided a copy of the general discharge permit,
technical bulletin and change of ownership form.
Effluent Pipe
Yes No NA NE
Is right of way to the outfall properly maintained?
■ n n n
Are the receiving water free of foam other than trace amounts and other debris?
■ n n n
If effluent (diffuser pipes are required) are they operating properly?
❑ n ■ n
Comment: Cascade bricks have been washed out and need to be replaced to provide
reaeration of the wastewater before entering the stream.
Septic Tank
Yes
No
NA
NE
(If pumps are used) Is an audible and visual alarm operational?
■
n
n
n
Is septic tank pumped on a schedule?
■
n
n
n
Are pumps or syphons operating properly?
n
n
■
n
Are high and low water alarms operating properly?
n
n
■
n
Comment: The alarm system appears to be for the old pump tank to the abandon
drain field. The replacement (SFR) system should flow by gravity through the filters to
the creek. A site diagram is included with this inspection report.
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: Dual sand filters are in place but no recirculation is required.
Disinfection -Tablet
Yes
No
NA
NE
Page # 4

a
Permit: NCG551169 Owner - Facility: Chad E. Davis - Residence
Inspection Date: 06/25/2008 Inspection Type: Compliance Evaluation
Disinfection -Tablet Yes
No
NA
NE
Are tablet chlorinators operational?
■
n
n
n
Are the tablets the proper size and type?
■
n
n
n
Number of tubes in use?
Is the level of chlorine residual acceptable?
n
n
n
■
Is the contact chamber free of growth, or sludge buildup?
■
n
❑
Cl
Is there chlorine residual prior to de -chlorination?
n
n
n
■
Comment: Chlorine chamber is bolted down and needs to bechecked to make usre
tablets are in contact with the water.
Page # 5

02-21-02 17:21` MORETZ ENGINEERING ID=7047394255 P01/03
Civil Design
Land Planning
Environmental Studies
FAXTR'ANSMISSImN
To: SAO AX QDU -- 4 4AZf4,,? .
Fax N:'7t+—(v(a— (oc *o
From: Lknix& CC>f,G rS
Subject:
OA
CAAMMTS-
Date: Z -z 1 02.
1pages: including this cover sheet.
Moretz Engineering •' 104 North DiAing Street, Kings Mountain, N.C. 28086
Fax [phone] Business [phone]

02-21-02 17:22 MORETZ ENGTTINEERING ID=7047394265 P02/03
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rn Michael F. Easley, Goveor
�O G
v� William G. Ross, Jr., Secretary
>_ __q North Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
23 May 2008
M ChadaF Day s
10 Hull Drive
Dallas, NC 28034- 5
Subjectingle Family Residence Wastewater Treatment
NPDES General ast-water Permit No./Certificate
of Coverag OG551169
Compliance*avialuationrInspection
Dear Mr. Davis:
Division of Water Quality (DWQ) database records show that you currently own/operate a single
family residence (SFR) wastewater treatment and disposal system. DWQ personriel'from the Mooresville
Regional Office (MRO) need to conduct a comprehensive review of your system with you .in -order to
verify -that your system is operating properly and to determine the compliance status of the system
pursuant to.your NCG551169 permit. We anticipate such a review would take approximately one to two
hours, piOided,that ;all, needed.documentation and, data js,.readily:available at, the, time, ,of the -site visit.
Due to thejdifficulties involved with catching owners at home during the. workday,.yve would like
to pre -schedule this.,site :visit -with you to ensure we can meet .and •complete,the. required -system: review_as
expeditiously as possible. In..order to facilitate this we ask -that you contact Mr. Ron Boone, of.our office;
at 7044-6634699, between the hours of 8AM and 4PM, Monday through Friday. Please contact Mr.
Boone.:within the next 10 days to identify the best possible time for an evaluator to visit your.SFR and
conduct this review ;with you.
Also, in the interest of conducting the most efficient evaluation possible, we ask, that. -you have
certain items of documentation on hand at the time of the site visit. These items include the following:
Permit/Certificate of Coverage: Issued by DWQ, you would have received this via regular U.S.
Postal Service mail.
2.: A' Schematic of the Treatment/Disposal System: Please have available .all schematics or other
technical drawings and/or design specifications that show the complete and/or partial layout of
`<r your treatment/disposal system.
3. Documentation ,of Analytical Monitoring: Required in Part I(A) of the, general ,NCG550000
permit, please have available all official records 'of analytical monitoring conducted to date..
41 ' Documentation of, Septic .,Tank Inspections/Pumping: , Required in Part ; I(A)., of, the , general
NCG550009,�permit, please have available all records of annual -septic ;tank; inspections;and:septic,
A pumping -
_ n z
S. ekorl ma6ri%Dechlorination Tablets: Please have available the original containers in which .
both the chlorination,.and dechlor-ination tablets ;were stored, when you purchased them:; ,.;,;�
North Carolina Division of Water Quality Mooresville Regional Office Surface Water Protection Phone [phone] Customer Service
Internet: h2o.enr.state.nc.us 610 East Center Avenue, Suite 301 Mooresville, NC 28115 FAX [phone]
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper Noi7tU olina
�Naiura!!11

Iniv OIL: _O _... .. :ice 'i: .). `:1`ii .I i:;���•�ii! lii"?('l� ,., iii J1;)1:'' 1��:, 'f!
L• .,:i`.!l, :r( )f ":'(' �(1 �Ii.`)I` +i .!1 .��,., .., .i _�, (.i , , �:JA➢(I(:� W �'i;'!.:.+ `,•'o ,a..,:, 1w trr r .!` t _ 7:, .ii::..:. .2.J mum f), J1i'ji';(II;
fIj`.;t;i`_ii_ spool! O n 1 lRJro ..c.:.intnow5v WOMS1 &I• `;
I!G unv fir:)(N .. odi inn ni i C.v007 jp YMN 01 w G a ' \: 'rthas n in IM60

Mr'. Chad E. Davis Single Family Residence Wastewater Treatment System
,
NCG551169 23 May 2008
We appreciate your time and understanding of our mission to preserve the natural resources of our
great state and look forward to you contacting us to schedule this site visit. If for some reason you're
unable. to contact us,, we will make every effort to contact you to schedule the review of your. system. If
you have questions or concerns about this letter or the required review, please contact Mr. Boone between
the hours of 8AM and 4PM, Monday through Friday at 70.4-663-1699. If he is not there when you call,
pleaseaeave your name and a good contact phone number and he will return your call as soon as possible.
Sincerely,
Robert B. Krebs
Surface Water Protection Section Supervisor
Division of Water Quality
5�
Mooresville Regional Office

17'

Form 101 NC Division of Water Quality
1/L
fin/ I Surface Water Protection S�ectio
/
SINGLE FAMILY V MENT/DISPOSAL SYSTEM FIELD
HECKLIST
Inspector Name(s) :
Date of Inspection:
Arrival Time:
Departure Time:
O v
o -�2.j6
Property O ner Name:
Phone Number(s):
Certificate of Coverage #:
ra
NCG55
Physical Address of Treatment System:
City:
Zip Code:
County.
l U L� r v e
'D, //, T
C/
Mailing Address of Property Owner:
City:
f' 5
Zip Code:
County:
�
U lG� 1 ari'v �
# Question I
Yes I
No
NIA
N/E -
Remarks:
Is the Permittee the current owner of the Single Family
1 Home? (Verify current ownership of the location
producing the discharge.)
II. System La
out/P rmittee's Knowledge/of System m
1 Does permittee have a map showing the layout of the / r
treatment system?
2 Does permittee know where the septic tank is located?
Does permittee know where the sandfilter(s) is/are
3 located?
4 Does permittee know where the Chlorinator is located?
Does permittee know where chlorine tablets go? If not,
5 instruct them.
Does permittee know where the dechlorination unit is?
(Only new facilities constructed after August 1, 2007 /
6 {Effective date of latest general permit} are required to
install dechlorination.)
7 I Does permittee know the location of the outlet/discharge?
2 I Does permittee have analytical monitoring results on site?
Is analytical monitoring conducted by a NC certified
3 laboratory?
Do analytical monitoring results show compliance with
4 permit limits? (Check for compliance with permit limits
using Form 102.)
V. S
P
:.::.:....::::.. .....,::,,.:::::.........
atic Tank ... ................ ..... .... .. ... ... .
1 Has the septic tank been pumped in last 3 to 5 years? If
yes, when?
Page 1 of 4 SFR Inspection Checklist.xls 6/20/2008, 8:59 AM

Are the chlorine tablets wastewater rated? (Inspect
1 original container for wastewater rating. If not, require
permittee to get tablets rated for wastewater.)
2 jAre there chlorine tablets in the chlorinator? V,
VII. Dechlorination
Are the dechlorination tablets wastewater rated? (Inspect
original container for wastewater rating. If not, require t
1 permittee to get tablets rated for wastewater. Only new
facilities constructed after August 1, 2007 {Effective date
of latest general permit} are required to install
dechlorination.) zt
Are there dechlorination tablets in the dechlorinator?
1 Is/are the pump(s) working? I/
2 Is the high water alarm in the pump tank operational?
Does the permittee know how to check the pump and
3 high water alarm to ensure operability?
X. Detecti
ng Possible Problems/System Failure
Is there any evidence of sewage surfacing or ponding
1 anywhere on the grounds?
2 1 Is there any overflow or soggy soils on the property?
Is there any sewage on the ground near the septic tank,
3 distribution box(es), sand filters or contact chambers,
indicating a possible failure of the system?
Does any area of the property appear to be greener with
4 vegetation growth than any where else on the property?
(Indicates a possible sandfilter failure.)
If standing sewage or possible system failure is observed,
5 are there signs of human and animal traffic in the area?
(Need to understand if human contact/vector concerns
are evident/prevalent.)
ffl n e & Discharge
XI. E ue t Pi e
P 9
:::::::::...:..::.::..:::.:::..:..:::..:..:..:...:..:..................................................................................................
1 Did you observe the end of the discharge pipe?
2 Was the outlet discharging?
3 Was the discharge clear and free of solids?
Is there any evidence of solids at the end of the pipe or in
4 nearby ditches or creeks?
Page 2 of 4 SFR Inspection Checklist.xls 6/20/2008, 8:59 AM

Form 101
NC Division of Water Quality
Surface Water Protection Section
# I Question I Yes I No I N/A I N/E I Remarks:
Is the outlet submerged in stream flow, or does it appear
that it may become submerged under slightly higher
5 stream flows? (Outlet should never be submerged.)
XII. Illegal Discharges
Is all wastewater from the home connected to drain into /
the septic tank? �/
Is there any discharge of gray water (i.e. washing
machine or dishwashing machine wastewater) from the
2 residence straight into the creek, ditch, stream, etc? (If
yes, then the discharge must be connected to drain into
the septic tank immediately. Any discharge of untreated
wastewater into the environment is illegal.)
NOTES:
Page 3 of 4 SFR Inspection Checklist.xls 6/20/2008, 8:59 AM

Form 102
PARAMETER
NOTES:
NC Division of Water Quality
Surface Water Protection Section
EFFLUENT LIMITATION COMPLIANCE CHECKLIST
LIMITS I MONITORING REQUIREMENTS I Monitoring Results
MONTHLY DAILY I MEASUREMENT I SAMPLE SAMPLE Year 1 Year 2 Year 3 Year 4 Year 5
AVERAGE MAXIMUM FREQUENCY TYPE LOCATION
• Page 4 of 4 SFR Inspection Checklist.xls
6/20/2008, 8:59 AM

GASTON COUNTY, NC YR
2007
REQUESTED BY G400SEC RUN 10/16/07 TIME 9:56:47
PAGE 1
THORNBIRD MEADOWS LORD ANNA
KEATON
LORD ANNA
KEATON
NBHD:
2D016 169115
ELK B L 26 110
HULL DR
110 HULL DR
3548-13-9076
PAR DESC3: REVAD
13 068 026 35 000 DALLAS
NC
28034-0000
DALLAS NC
28034-0000
110 HULL DR
Plat Bk/Pg 040 041 1476383
1476383
Bldg No. 1 Appraiser: LBS
Appr Date: 4/22/2004
APPR: LBS
APPR DT: 6/13/2006
LAND VALUE
30,000
30,000
Imp Desc: R1H RESIDENTIAL 1.5
STORY Eff Yr:
USE CODE:
1111 SINGLE FAMILY
MISC VALUE
0
0
Grade C AVERAGE QLTY
100
Act Yr Bt:
1997 DISTRICT:
270 AG. CENTER FD
BLDG VALUE
149,099
149,099
1.70 Stories/ 8 Rms/ 4
Bed/
2.5 Bth/
HBth NBHD: 2D016 HANNON DR AREA (53
TOTAL VALUE
179,099
179,099
Finished Area: 1,999.20
ASV SgFt
89.59 Sales SgFt
104.04 2006
PRIOR YEAR
156,067
156,067
COMPONENT TYPE/CODE/DESC
PCT
UNITS
RATE STR##
STR% SIZ% HGT%
PER% CDS%
COST %CMPL
-----------------------------------------------------------------------------------------------------------------------
AC R11 COVERED PORCH
100
156.00
25.05
100.00
3,907
AC R11 COVERED PORCH
100
264.00
25.05
98.00
6,480
AC R12 ENCLOSED PORCH FRAME
100
60.00
41.85
104.00
2,611
AC R13A ATCHD FR GAR W/UPPER
NIA R1H RES 1.5 STORY
100
100
576.00
1176.00
44.90
78.30 1.70
100.00
92.00
25,862
84,714
J
MA R1H (UPPER FLOORS)
100
823.20
78.30 1.70
50.00 92.00
29,650
��
- AR 10 FHA W-A/C
100
1176.00
2.50
2,940
- BI 20 Adequate
100
1.00
.00
0-
EW 02 VINYL
100
1176.00
.00
92 00
f\
- FC 25 TI E/CARPETG
100
1176.00
.00
0
I j
- FN 03 CONT WALL BRK
100
1176.00
.00
92.00
0
- IF O1 DRYWALL
100
1176.00
.00
0
- PL Y ADDED FIXTURES YES
100
8.00
960.00
7,680
^CF)
�k
- RC 08 ASPHALT SHINGLES
100
1176.00
.00
0
- RT 03 DOUBLE PITCH
100
1176.00
.00
0
RCN...
PCT COMPLETE
100 x
163,844
QUAL..
QG C
AVERAGE
QLTY 100
100.00 x
163,844
DEPR..
AV
AVERAGE
CDU
9.00 -
14,745
14,745
T
--FMV...
MKT 2D016 HANNON DR AREA (539)
100.00 x
149,099
I
PROPERTY NOTES:
BOOK
PAGE DT
DATE QS
SALES PRICE
4352
0587 WD
9/12/2007 =
208,000
PERMIT
NO TYPE
DATE
AMOUNT
0088804
800
3/25/2004
BLDG CODE DESC
UNITS
EYE DT PCT
ADD.DEPR PCT QGCD VALUE
.00
.00
.00
.00
LND LAND TOTAL ACRES:
1.260
TOT
CURRENT
## ZONE TYPE/CODE LAND
QTY LAND ACRES LAND RATE DPTH DPT% TOP% LOC%
SIZ% SHP%
OTH% ADJ
FMV EXMPT
1 LT RE
1.000
1.260
.00
.00 .00 .00
.00 .00
.00 .00
30,000
169115 110
HULL
DR

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u . .
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� . .
, s .
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. .
�
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. .
'
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. .
o �
. o
. .
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B~ AC azl conE000 PORCH o~ AC Rll COVERED eoRco
c~ AC R12 ENCLOSED PORCH FRAME

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bEHZ PuTToaPD ggaoN 'SPTTPQ
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uo-.sPD. :AqunoD.
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Yes x No If No, explain:
8. Topography (relationship to flood plain included): Sloping
toward the creek at the rate of 5-to 60. The site is not
located in a flood plain.
9. Location of nearest dwelling: The nearest dwelling (the
applicant's house) is approximately 25 feet from the site.
No other -dwellings within 200 ft of the site.
10. Receiving stream or affected surface waters: Little Long
Creek.
a. Classification: C
b. River Basin and Subbasin No.: Catawba 030836
C. Describe receiving stream features and pertinent
downstream uses: The receiving stream flow was
approximately 5 feet wide and 3 to 4 inches deep at the
time of investigation. There are no known users
downstream.
PART II - DESCRIPTION OF DISCHARGE AND TREATMENT WORKS
1. a. Volume of wastewater to be permitted: 0.000360 MGD
(Ultimate Design Capacity)
b. What is the current permitted capacity of the
wastewater treatment facility? N/A
C. Actual treatment capacity of the current facility
(current design capacity)? N/A
d. Date(s) and construction activities allowed by previous
Authorizations to Construct issued in the previous two
years: N/A
e. Please provide a description of existing or
substantially constructed wastewater treatment
facilities: N/A
f. Please provide a description of proposed wastewater.
treatment facilities: The proposed wastewater
treatment facilities will consist of a septic tank, two
sand filters in series, chlorination, contact chamber
and cascade aeration.
NPDES Permit Staff Report
Page 2

J
g. Possible toxic impacts to surface waters: None other
than chlorine.
h. Pretreatment Program (POTWs only): N/A
2. Residuals handling and utilization/disposal scheme:
a. If residuals are being land applied, please specify DWQ
Permit No.: N/A
d. Other disposal/utilization scheme (specify): Waste
sludge to be removed by a septic tank contractor as
needed.
3. Treatment plant classification (attach completed rating
sheet): Class I
4. SIC Code(s): 9999
Wastewater Code(s) of actual wastewater, not particular
facilities, i.e., non -contact cooling water discharge from a
metal plating company would be 14, not 56.
Primary: 04 Secondary:
Main Treatment Unit Code: 44007
PART III - OTHER PERTINENT INFORMATION
1. Is this facility being constructed with Construction Grant
Funds or are any public monies involved (municipals only)?
N/A
2. Special monitoring or limitations (including toxicity)
requests: N/A
3. Important SOC, JOC or Compliance Schedule dates: (please
indicate)
4. Alternative Analysis Evaluation: Has the facility evaluated
all of the non -discharge options available. Please provide
regional perspective for each option evaluated.
Spray Irrigation: Space is very limited.for such activity.
Connection to Regional Sewer System:
in the vicinity.
NPDES Permit Staff Report
Page 3
There is no sewer line

Subsurface: Soil condition is poor. Application for a
septic system has been denied by the County.
Other Disposal Options: N/A
5. Air Quality and/or Groundwater concerns or hazardous
materials utilized at this facility that may impact water
quality, air quality, or groundwater: N/A
6. Other Special Items: N/A
PART IV - EVALUATION AND RECObMNDATIONs
Mr. Sanderson has applied for a permit to construct a
surface sand filter system for his residence. The existing
septic tank field system has failed and, according to'the Health
Department,'the soil at his property is not suitable for any type
of wastewater ground adsorption system or repair. (Letter
enclosed).
Pending receipt and approval of the waste load allocation,
it is recommended that the NPDES permit be issued.
Signature of
rt Preparer
Water Quality Regional Supervisor
Date
NPDES Permit Staff Report
Page 4

41
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USE
AgeDivision of Water Quality / Water Quality Section
r AEN�
National Pollutant Discharge Elimination System
NCpE�NR
NCG550000
NOTICE OF INTENT
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: Mike Parker Date: 5-9-01
2) Mailing address of owner/operator:
Owner Name Gary Sanderson -
Street Address 110 Hull D r i v - -
City Dallas State. N. C. ZIP Code 28034
Telephone No. (Home) 7 0 4 9 2 2- 812 3 (Work) 7 0
' Address to which all permit correspondence will be mailed
3) Location of facility producing discharge:
Street -Address Same
City State ZIP Code
County
Telephone No.
4) Physical location information: ���� � ?jZ/ n
Please provide a narrative description of how to get to "efacili (use street names, s—tate roa
numbers, and distance and direction from a roadway intersection). Old -U.S. 321 N .Left on
Thornburg Rd Left on Hannon St , , r eft On i LIJ Rct . at enr9 of Cul-De-Sac
5) This NPDES permit application applies to which of the following
New or Proposed (system not constructed)
Existing (system constructed); If previously permitted by local or county health department,
please provide the permit number and issue date
Modification; please describe the nature of the modification:
6) Description of Discharger (;
a) Amount of wastewater to be discharged:
Number of bedrooms 3 x 120 gallons per bedroom = 360
sWU-216-062199
Page 1 of 3
r
gallons per day to be permitted

NCG550000 N.O.I.
b) Type of facility producing waste (please check one):
IN Primary residence ❑ Vacation/second home
❑ Other:
7) Please check the components that comprise the wastewater treatment system:
Septic tank ❑ Dosing tank
❑ Primary sand filter ® Secondary sand filter ❑ Recirculating sand filter(s) "
❑ Chlorination ® Dechlorination ❑ Other form of disinfection:
13 Post Aeration (specify type) Cascade
8) For new or proposed systems only - Please address the feasibility of alternatives to
discharging for the following options in the cover letter for this application:
a) Connection to a Regional Sewer Collection System.
b) Letter from local or county health department describing the suitability or non -suitability of the site
for all types of wastewater ground adsorption systems.
c) Investigate Land Application such as spray irrigation or drip irrigation.
9) 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? Carpenters Branch
b) Stream Classification (if known): Not Known
10) The application must include the following or it will be returned:
a) For Certificates of Coverage:
❑ An original letter and two (2) copies requesting a general permit
❑ A signed and completed original and two (2) copies of this document.
❑ A check or money order for the permit fee of $50.00 made payable to NCDENR.
❑ Invoice showing that the septic tank has been pumped and serviced within the last 2 years
(for existing facilities only).
New or proposed facilities must also include:
❑ Letter from the county health department evaluating the proposed site for all types of ground
absorption systems.
❑ Evaluation of connection ion regional sewer system (approximate. distance & cost to connect).
b) For an Authorization to Construct (ATC) only:
❑ A letter requesting an ATC
❑ Three sets of plans and specifications of proposed treatment system (see Permit Application
Checklist and Design Criteria for Single Family Discharge)
❑ Invoice showing that the septic tank has been pumped and serviced (for existing septic
tanks).
Note: There is no fee when requesting an Authorization to Construct
Page 2 of 3
SWU-216-062199

NCG550000 N.O.I.
11) Additional Application Requirements:
a) If this application is being submitted by a consulting engineer.(or engineering firm),. include
documentation from the applicant showing that the engineer (Or firm) submitting the application
has been designated an authorized Representative of the applicant.
b) If this application is being submitted by a consulting engineer (or engineering firm), 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".
c) . If this application is being submitted by a consulting engineer (or engineering firm), 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.
12) 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: v y o u Ili
Title:
(Signature of Applicant) (Date Signed)
North Carolina Genera[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 $10,000, 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 $10,000 or imprisonment
not more than 5 years, or both, for a similar offense.)
Notice of Intent must be accompanied by a check or money order for $50.00 made payable to:
NCDENR
Mail three (3) copies of the entire package to:
Stormwater and General Permits Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Note
The submission of this document does not guarantee the issuance of an NPDES permit
Page 3 of 3
SW U-216-062199

0(3 14- 01 1R: 1-1 FAS
STANLEY SEPTIC SERVICE, INC.
P.O. BOX 184
STANLEY, NC 28.164
PHONE: [phone]
FAX: [phone]
BILL TO
Gary Sande snn
110 Hull Drive
Da]Ius, NC 29034
Phona
704-922-9123
QUANTITY -DESCRIPTION
r pump I WO Gallon SeNc Tank
I J p=p 1000 Gallon hiwp Tank
I Service Date_ Matzh 19, 2001 -
We apprtxiute your business!
Invoice
DATE INVOICE #
6/11101 4399
P_O_ NO. I TERMS PROJECT
Due ou receipt
RATE AMOUNT
11 270.00 270.00
Total S270.00
AF,-14-fat 06:50 TO:MORETZ ENGINEERING
FROM: P02

SOC PRIORITY PROJECT: Yes —No x
If Yes, SOC No.
To: Permits and Engineering Unit
Water Quality Section
Attention: Mack Wiggins
Date: August 17, 2001
NPDES STAFF REPORT AND RECOMMENDATION
County: Gaston
Permit No. NCG550018
PART I - GENERAL INFORMATION
1. Facility and Address: Timothy Lee Smithers Residence
4521 Regal Oaks Rd.
Gastonia, North Carolina 28056
2. Date of Investigation: August 7, 2001
3. Report Prepared By: Samar Bou-Ghazale. Env. Engineer I
4. Persons Contacted and Telephone Number: 'Mr. Jerry Cook, Tel#
[phone]
5. Directions to Site: From the intersection of Highway 7 and
Beechbrook Road (SR 2099) in Belmont, travel north on SR
2099 approximately 250 feet to Hillcrest Drive. Turn right
on Hillcrest Dr. and travel approximately 0.4 mile -to the
intersection with Eastwood Drive. Turn right on Eastwwod
drive and travel approximately 200 feet to the proposed site
located on the right.
6. Discharge Point(s). List for all discharge points:
Latitude: 35°15'46"
Longitude: 81003'38
Attach a U.S.G.S. map extract and indicate treatment
facility site and discharge point on map.
U.S.G.S. Quad No.: F 14 SE U.S.G.S. Name: Mount Holly,
N.C.
7. Site size and expansion are consistent with application?
Yes x No_ If No, explain:

8. Topography (relationship to flood plain included): Sloping
toward the creek at the rate of 8 to 100. The site is not
located in a flood plain.
9. Location of nearest dwelling: The nearest dwelling is
approximately 200 feet from the site.
10. Receiving stream or affected surface waters: Unnamed
tributary to Catawba River.
a. Classification: WS-V
b. River Basin and Subbasin No.: Catawba 030836
C. Describe receiving stream features and pertinent
downstream uses: The receiving stream flow was
approximately 5 feet wide and 3 to 4 inches deep at the
time of investigation. There are no known users
downstream.
PART II - DESCRIPTION OF DISCHARGE AND TREATMENT WORKS
1. a. Volume of wastewater to be permitted: 0.000450 MGD
(Ultimate Design Capacity)
b. What is the current permitted capacity of the
wastewater treatment facility? N/A
C. Actual treatment capacity of the current facility
(current design capacity)? N/A
d. Date(s) and construction activities allowed by previous
Authorizations to Construct issued in the previous two
years: N/A
e. Please provide a description of existing or
substantially constructed wastewater treatment
facilities: N/A
f. Please provide a description of proposed wastewater
treatment facilities: The proposed wastewater
treatment facilities will consist of a septic tank, a
sand filter, chlorination and contact chamber.
g. Possible toxic impacts to surface waters: None other
than chlorine.
NPDES Permit Staff Report
Page 2 .

c
h. Pretreatment Program (POTWs only).: N/A
2. Residuals handling and utilization/disposal scheme:
a. If residuals are -being land applied, please specify DWQ
Permit No.: N/A
d. Other disposal/utilization scheme (specify): Waste
sludge to be removed by a septic tank contractor as
needed.
3. Treatment plant classification (attach completed rating
sheet): Class I
4. SIC Code(s): 9999
Wastewater Code(s) of actual wastewater, not particular
facilities, i.e., non -contact cooling water discharge from a
metal plating company would be 14, not,56.
Primary: 04 Secondary:
Main Treatment Unit Code: 44007
PART III - OTHER PERTINENT INFORMATION
1. Is this facility being constructed with Construction Grant
Funds or are any public monies involved (municipals only)?
N/A
2. Special monitoring or limitations (including toxicity)
requests: N/A
3. Important SOC, JOC or Compliance Schedule dates: (please
indicate)
4. Alternative Analysis Evaluation: Has the facility evaluated
all of the non -discharge options available. Please provide
regional perspective for each option evaluated.
Spray Irrigation: Space is very limited for such activity.
Connection to Regional Sewer System: There is no sewer line
in the vicinity.
Subsurface: Soil condition.is poor. Application for a
septic system has been denied.
NPDES Permit Staff Report
Page 3

Other Disposal Options: N/A
5. Air Quality and/or Groundwater concerns or hazardous
materials utilized at this facility that may impact water
quality, air quality, or groundwater: N/A
6. Other Special Items: The original permit was issued to a
former owner of the property. However, the previous owner
did not construct any wastewater treatment facilities.
PART IV EVALUATION AND RECOMNdENDATIONS
Mr. Smithers has applied for a permit to construct a surface
sand filter system for one residence on lots 23 and 24.
This office obtained a letter from the Gaston County Health
Department stating that lots 17, 18, 23, and 24 in Beechbrook
Subdivision, Block 3, are not suitable for any type of ground
absorption wastewater system.
The discharge for the facility is proposed to be into a dry
ditch tributary to the creek. It is recommended that the
discharge pipe be extended to the creek which borders the
property.
Pending receipt and approval of the waste load allocation,
it is recommended that the NPDES permit be issued with the above
condition.
Signature of Report Preparer
Water Quality Regional Supervisor
Date
NPDES Permit Staff Report
Page 4

02-21-62 O9:23-MORETZ ENGINEERING
ID=79�7394265
Civil Design
Land Planning
Environmental Studies
i
FAX TRANSMISSION
To:t5�POAAF. LOU -- G}{-f,� .Date:
F2x #: Pages: including this cover sheet.
From: L419-Mk Go
Subject: SAW orl kz' t l`zf'r�
CpNMMNTS:
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Moretz Engineering - 104 North D111in Street, IGn s Mountain. N.C. 28086 /
�. 9 s s
Fax [phone] Business [phone] r � ,

ATF�
o'
Mr. Gary Sanderson
110 Hull Drive
Dallas, NC 28034
Dear Mr. Sanderson:
Michael F. Easley
'.i• +., 4'y`_�l' Governor
William.G. Ross, Jr., Secretary
Department of Environment and Natural Resources
Gregory J. Thorpe, Ph.D
Acting Director
Division of Water Quality
January 9, 2002
Subject: Application No. NCG551169
Gary.Sanderson Residence
Gaston:Counfy -�-
This is to acknowledge receipt of the following documents on January 12, 2002:
X Completed Notice of Intent (Application form),
Engineering Proposal (for proposed control facilities),
Request for certificate of coverage
X Application processing fee of $50.00.
Engineering Economics Alternatives Analysis,
X Engineering Plans and Specifications
Local Government Signoff,
Source Reduction and.Recycling,
Interbasin Transfer,
X Other: Septic tare service receipt.
MC DEPT OF EWRONMT
AND NATURAL RESOURCES
UOORESVILLE REGIONAL OFFICE
r- -
�AN 2 8 2002 7
r ry
If
WATER QUALITY SEC1111%
The items checked below are needed before review can begin:
Completed Notice of Intent (Application Form),
Engineering proposal (see attachment),
Application Processing Fee of $00.00, p`L <���� i
Delegation of Authority (see attached), N, , `
Biocide Sheet (see attached),
Engineering Economics Alternatives Analysis,
Engineering Plans and Specifications
Local Government Signoff,
Source Reduction and Recycling,
Interbasin Transfer, _
Other: /�, 7 2, ®G� / y -6
`l
If the application is not made complete within thirty (30) days, it will be returned to you and may be resubmitted when
complete.
NCDENR
Customer Service Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 [phone]
1 800 623-7748

aQF w A rFR Michael F. Easley
Governor
Uj William G. Ross, Jr., Secretary
Department of Environment and Natural Resources
p `C Gregory J. Thorpe, Ph.D
Acting Director
Division of Water Quality
This application has been assigned to Mack Wiggins (919/733-5083) Ext. 542 of our Permits Unit for review. You will be
advised of any comments, recommendations, questions or other information necessary for the review of the application.
I am, by copy of this letter, requesting that our Regional Office Supervisor prepare a staff report and recommendations
regarding this discharge. If you have any questions regarding this application, please contact the review person listed
above.
Sincerely,
f6
Wiggins
Stormwater and General Permits Unit
cc: Mooresville Regional Office
Permit Application File
VXF
NCUENR
Customer Service
1 800 623-7748
Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 [phone]