NCG550103_Compliance Evaluation Inspection_20210727

United States Environmental Protection Agency
E PA Washington, D.C. 20460
Water Compliance Inspection Report
Form Approved.
OMB No. 2040-0057
Approval expires 8-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction
1
21IIIIII
Inspection
671
Code NPDES yr/mo/day Inspection
IN I 2 LI 3 I NCG550103 111 121 21/07/27 117
Type
1810I
IIIIIIIIIII
Inspector Fac Type
19I S I 2011
IIIIIIIIIII IIIIIII I IIIIII
P6
Work Days Facility Self -Monitoring Evaluation Rating B1 QA Reserved
I 70I3 I 711 1 72 I N I 731 1 74 71
I I
I I I I I I 180
Section B: Facility Data
Name and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
POTW name and NPDES oermit Number)
4660 Doveland Circle
4660 Doveland Cir
Winston Salem NC 27127
Entry Time/Date
02:OOPM 21/07/27
Permit Effective Date
18/10/30
Exit Time/Date
02:30PM 21/07/27
Permit Expiration Date
20/10/31
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
Peggy S Simmons,4660 Doveland Cir Winston Salem NC 27127///
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
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
Alex Lowe DWR/WSRO WQ/336-776-9689/
Signature
of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
DocuSigned by: FL—e, 'T. 3A,acr 8/2/2021
145B49E225C94EA...
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
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3I
NPDES yr/mo/day
N CG550103 111 121 21/07/27
I17
Inspection Type
18 [j
(Cont.)
1
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
On Tuesday, July 27, 2021, Alex Lowe of the WSRO conducted a routine Compliance Evaluation
Inspection of the Single -Family Residence treatment system at 4660 Doveland Circle. Mr. Simmons
direceted Lowe to the points of interest along the waste treatment system, and shared the
documentation available for review.
It was noted that the permit held by Ms. Peggy Simmons was expired in October of 2020, so Lowe
provided a copy of the paperwork needed to renew the permit, and explained the renewal process.
Mr. Simmons stated that he would return the application to Raleigh Central Office promptly. Despite
the permit falling out of date, no lapse in yearly fees had occured.
Lowe was unable to observe the chlorination chamber, as the concrete lid was too heavy to lift alone,
and neither Mr. nor Ms. Simmons could provide assistance due to the intense heat. Mr. Simmons
stated that he has a few neighbors who will help him remove the tank lid every few weeks when the
chlorine tablets are due to be replaced.
Mr. Simmons provided proof of the septic tank was pumped on 9/30/2019
Upon review of the system, the sand filter appears to be removing all solids, and the chlorination
tablets are being properly monitored and regularly replaced.
Page# 2

Permit: NCG550103
Inspection Date: 07/27/2021
Owner - Facility: 4660 Doveland Circle
Inspection Type: Compliance Evaluation
Yes No NA NE
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