NCG550103_Renewal (Application)_20210729

STATE
ROY COOPER
Governor 11}
ELIZABETH S.BISER
Secretary
S.DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
August 01, 2021
Peggy Simmons
4660 Doveland Cir
Winston Salem, NC 27127
Subject: Permit Renewal
Application No. NCG550103
4660 Doveland Circle
Forsyth County
Dear Applicant:
The Water Quality Permitting Section acknowledges the July 29, 2021 receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 150B-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit.The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https://deq.nc.gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
Sincerely,
ti
elk
Wren Th-dford
Administrative Assistant
Water Quality Permitting Section
ec: WQPS Laserfiche File w/application
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Winston-Salemrolina D Regionalme Office vi450onme West Hanes Mill Road,Dvi Suiteionof 300Wter I Winston-Soces alem,North Carolina 27105
i a^+iZma nNiero, 336.776.9800

PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
Water Resources S. JAY ZIMMERMAN
ENVIRONMENTAL QUALITY
Director
RENEWAL FORM FOR EXISTING PERMITTED FACILITIES
NPDES renewal application for continued coverage under General Permit NCG550000:
Certificate of Coverage NCG55 0103
(Please verify the information in items 1 &2 as correct, or note any corrections that should be made.)
(Please print or type)
1) Mailing address*of property owner:
. ►Owner Name v.; A t Pel q� -57:/vg-x)
Street Address 466'D D Yee/Mid 6;76/e
h/,' /d / ,2 71� 7
City s�f�/
Telephone (Home)23k ! /6,--3 (Mobile) 830 �y
9 gi�-��
(e-mail address) Jj,�� V'fi�� y_S� ,L� GZ4� " RECEIVED
*Address to which all permit correspondence will be mailed
JUL 292021
2) Location of facility producing discharge*: '/
Street Address e rs' Q V NCDEQIDWRINPDES
City:
County •
Telephone (Home)_ (Mobile)
*If the facility is not yet constructed, give the street address or lot number where the structure will be
built.
3) Description of Discharge:
a) Type of facility producing waste (please check one):
Primary residence
❑ Vacation/second home
❑ Undeveloped property
❑ Other [describe]:
Page 1 of 2

NCG550000 renewal form
4) Please check the components that comprise the wastewater treatment system:
Septic tank 0 Dosing tank X Primary sand filter 0 Secondary sand filter
❑ Recirculating sand filter(s) A Chlorination ❑ Dechlorination
0 Other form of disinfection: 0 Post Aeration(describe)
5) Other Information:a) When was the septic tank last pumped out? 06/1 9
NOTE: the septic tank must be pumped out at least once every 3-5 years b) Is the facility [home] occupied year-round, or only seasonally? ����) � r©m .
c) Approximately how many people use the facility when it is occupied?
d) When was the wastewater system installed? /9 7 8
6) 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: /;fy
GI.) -1-9114
(Sig/Ea uPe of Applicant) Date S gned)
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 this completed form and a copy of the receipt for your last septic service to:
Charles H. Weaver
NC DEQ/DWR/NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
Page 2 of 2

INVOICE
-TRANSOU'S SEPTIC
TANK
XAK SERVICE, INC.
443
INVOICE CLEMMONS,NC 27012
[phone] .1
No. 32130 [phone] DATE I =�'
AMOUNT ENCLOSED
17
6.
DATES:
TO INSURE PROPER CREDIT,PLEASE RETURN THIS PORTION WITH PAYMENT
DESCRIPTION CHARGES CREDITS BALANCE
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i me ou. PAY LAST AMOUNT IN THIS COLUMN_ .
TRANSOU'S SEPTIC TANK SERVICE,INC.
1%/per month SERVICE CHARGE CLEMMONSX 1443 27012
after 30 days. _!,�_