NCG550112_Owner (Name Change)_20211026

•
ROY COOPER
-� r
\.,41:14
Governor �t r t�
ELIZABETH S.BISER C� . ;
Secretary -
— S.DANIEL SMITH NORTH CAROLINA �r'��VE®
Director Environmental Quality
OCT 262021
October 8,2021 NCDEQIDWRINPDES
154 Woodlawn Drive
Stoneville,NC 27248
SUBJECT:General Wastewater Permit Compliance Inspection Report
NPDES WW Permit No.NCG550112
Rockingham County
Dear Resident:
On September 20,2021,Jordan Burbage of the North Carolina Division of Water Resources conducted an inspection of the
wastewater treatment system serving your single family residence at 154 Woodlawn Drive.This inspection was conducted to
verify that the system is operating in compliance with the conditions and limitations outlined in your permit. The findings noted
during this inspection are provided in the enclosed copy of the inspection report.
State records indicate that your Certificate of Coverage has elapsed,and the$60 annual renewal fee billed by the Central
Office was due on 9/2/2021.Since you are a new homeowner,you will need to complete the enclosed Change of Ownership
form and mail it into Central Office in a timely manner.If you should have any questions,please do not hesitate to contact
Jordan Burbage with the Water Quality Regional Operations in the Winston-Salem Regional Office at 336-776-9697 or via
email at [e-mail].
Sincerely,
Docui d by:
L.af. T. cr
Lon T.Snider,Regional Supervisor
Water Quality Regional Operations Section
Winston-Salem Regional Office
Division of Water Resources, NCDEQ
Enclosed: Water Compliance Inspection Report
Change of Ownership Form
cc: WQS Winston-Salem Regional Office-Enforcement File
NPDES Compliance/Enforcement Unit-Enforcement File
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office t 450 West Hanes MITI Road,Suite 300 I Winston-Salem,North Carolina 27105
n,Wt11N:K l'`a 0
umv.+afffi...m+all 336.776, 800

ROY COOPER
Governor
MICHAEL S. REGAN
secreloty
LINDA CULPEPPER
Water Resources Irter=arecror
ENVIRONMENTAL QUALITY
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NC00 / / 1 / or NCG5 5/0/ I / I /
1. Facility Name: ,\174
IL NEW OWNER/NAME INFORMATION: RECEIVED
1. This request for a name change is a result of 1!
OCT 2 6 2021
X a Change in ownership of property/company
b. Name change only NCDEQ/DWRINPDES
• c. Other(please explain):
2. New owners name(name to be put on permit):
/1tGra—�,✓l 1p,
3. New owner's or signing official's name and title: � .ci 1 f11 1 �• S �✓,t ��
(Person legally responsible for permit)
01,une r
- ((Title)
4. Mailing address: S _l '00j Lon Pr, City: S hma
State:X/�- Zip Code: 70 t(e Phone:( 5 eS) 6
E-mail address: ipepp e i©r1 6 D 1-M cq,
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
[see reverse side of this page for signature requirements]
State of North Carolina f Environmental Quality Water Resources
1617 Mail Service Center I Raleigh,NC 27699-1617
919 807 6300 919-807-6389 FAX
hops://deq.nc.gov/about/divisionsiwater-resources/water-resources-permits/wastewater-branch/npdes-wastewater-permits

NPDES Name&Ownership Change
Page2of2
Applicant's Certification:
fri ar b✓l P, , 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 and attachments are not included,this application
package will be returned as incomplete.
Signature: � Date:
l 9//f/ .Z/
THE COMPLETED APPLICATION PACKAGE,INCLUDING ALL SUPPORTING
' INFORMATION&MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS._--
NC DEQ/DWR/NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 11/2017

Exhibit"A"
Beginning at an iron in the Southwestern margin of Woodlawn Drive(formerly known as
Lakeside Drive and SR#2244 and hereimalier referred to as Woodlawn Drive),said iron marking
a common corner of Lots 59 and 60;thence along the Southwestern margin of Woodlawn Drive,
South 43 deg.2T East 137.00 feet to an iron,a common corner of Lots 58 and 59;thence leaving
the Southwestern margin of Woodlawn Drive and traveling South 55 deg. 15'West 209.00 feet
to an iron marking a common corner of Lots 53,58 and 59;thence North 79 deg.59'West 68.54
feet to an iwu on the Eastern margin of a lake;thence along the Eastern margin of the Iake,
North 0 deg. 11'West 20.77 feet to an iron,a common rear corner of Lots 59 and 60;thence
North 38 deg.00'Rist 235.85 feet to an iron in the Southwestern margin of Woodlawn Drive,
the point of beginning,containing 0.54 acres,and being all of Lot 59 of Riverbend Subdivision,
as per Plat of Survey for Edward F.Staples,Mayo Township,Rockingham County,NC,dated --
September 19,1991,by May,Coleman&Terrell Land Surveying,William S.May,Jr.R.L.S,
Wentworth,NC.See Map Book 16,Page 29.Deed Reference;Deed Book 711,Page 809,Deed
Book 816,Page 2052,Rockingham County Registry.Together with improvement located
thereon;said property being located at 154 Woodlawn Drive,Stoneville,North Carolina.
• Parcel ID#132695
Property Address: 154 Woodlawn Drive,Stoneville,NC 27048
NC Bar Association Form No_3.. 1976,Revised 1/112010
Primed by Apemen with the NC Bar Association
I

Firefox aboaltblank
Exhibit"A"
Beginning at an iron in the Southwestern margin of Woodlawn Drive(formerly known as
Lakeside Drive and SR#2244 and hereinafter referred to as Woodlawn Drive),said iron marking
a common corner of Lots 59 and 60;thence along the Southwestern margin of Woodlawn Drive,
South 43 deg.27'East 137.00 feet to an iron,a common corner of Lots 58 and 59;thence leaving
the Southwestern margin of Woodlawn Drive and traveling South 55 deg: 15'West 209.00 feet
to an iron marking a common corner of Lots 53,58 and 59;thence North 79 deg.59'West 68.54
feet to an iron on the Eastern margin of a lake;thence along the Eastern margin of the lake,
North 0 deg. 11'West 20.77 feet to an iron,a common rear corner of Lots 59 and 60;thence
North 38 deg.00'East 235.85 feet to an iron in the Southwestern margin of Woodlawn Drive,
the point of beginning,containing 0.54 acres,and being all of Lot 59 of Riverbend Subdivision,
• as per Plat of Survey for Edward F.Staples,Mayo Township,Rockingham County,NC,dated
September 19, 1991,by May,Coleman&Terrell Land Surveying,William S.May,1r.R_L.S,
Wentworth,NC.See Map Book 16,Page 29.Deed Reference;Deed Book 711,Page 809,Deed
Book 816,Page 2052,Rockingham County Registry.Together with improvement located
thereon;said property being located at 154 Woodlawn Drive,Stoneville,North Carolina.
Parcel ID#132695
Property Address: 154 Woodlawn Drive,Stoneville,NC 27048
NC gat Associmioa Form No.3 1976.Revised 1,12010
Primed by A1st.a..,-1 web the NC Eat Association
6 of 12 10/23/20,1:16 PM

to the Grantee in fee simple_
And the Grantor covenants with the Grantee,that Grantor is seized of the premises in fee simple,has the right to
convey the same in fee simple,that title is marketable and free and clear ofall encumbrances,and that Grantor will
warrant and defend the title against the lawful claims afali persons whom °ea except forthe exceptions hereinafter
stated.
Title to the property hereinabove described is subject to the following exceptions:
Escauents,rights-of-way,and restrictions of record or visible upon the described pluycity,and to ad valorem taxes
for the current yeas_
IN WITNESS WHEREOF,the Grantor has hereunto set his hand,or if corporate,has caused this to be signed in its
corporate name by its duly authorized officers by authority of its Board of Directors,the day and year first above
written.
Family Trust of Ray Arthur Case
By: \\"tip
David Ray as Successor Trustee of the Family Trust of Ray Arthur Case dated October 19,2004
and as Executor of the Estate of Ray Arthur Case (20 E 104)
STATE OF / AS
COUNTY OF O AL vEST A/
1, grArzj, I(1iffie:f Cf' ,Notary Public,do hereby certify that David Ray Case,Trustee of Family Trust of
Ray Arthur Case dated October 19,2004 and as Executor of the Fslate of Ray Arthur Case(20 E 104)personally
appeared before me this day and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal this 2.retday of October,2020.
"(t14I
Official Signature of Notary
Printed or typed name of Notary ,�`�y,'r v8, RUSTY FU IGENCE
' ���N Public. of
My Commission Expires: 62.-Dj� o: J&E Comm.otary Expires
State 01-03-Texas2024
Notary ID 132341642
•
NC Bsr Association Form No.3. 1978,Revised . I/1.2010
Primed by Agreement with de NC Bar Association
5

NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: S250.00 Parcel Identifier No.: 132695
Mail after recording,to:Grantee(s)
This instrument was prepared by: Stegall&Clifford,PLI.C,445 Dailey Madison Road,Suite 102,Greensboro,NC 27410
Brief Description from the Index: Lot 59,Riverhead
THIS DEED made this 23 day of October,2020,by and between
GRANTOR GRANTEE
David Ray L'a�, Successor Trustee of Family Trust of Ray Martin D.Stull,II,unmarried
Arthur Case,dated October 19,2004 and Executor of the
Estate of Ray Arthur Case(20 E 104) Property Address:I54Waodlawn Drive,Stoneville,NC
27048
Mailing Address:12301 32nd Street
Sante Fe,TX 77510
The designation Grantorand Grantee as used herein shall include said parties,their heirs,successors,and assigns,and
ch'tl include singular,plural,masculine,feminine or neuter as requited by contest
WITNESSETII,that the Grantor,fora valuable consideration paid by the Grantee,the receipt of which is hereby
acknowledged,has and by thrcr'presents does grant,bar gdi s,sell and convey unto the Grantee in fee ale,all that
certain lot or parcel of laird situated in Mayo,City of Stoneville,Rockinubam County,North Carolina and more
particularly described as fbIlosys
See Erbibit A Attached Hereto and Made a Part Hereof'
Is the property the primary residence of the Grantors?No •
The property her=;u described vas acquired by Grantor by instrument recorded in Book 1278,Page 103t5,
•
Rockingham County Registry.
A map showing the above described property is recorded in Plat Book JA Page 29 and referenced rvi:hin this -
istrument
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances thereto belonging
NC Bar Association Farm No_3. 1976.Revised _ 1/1L2010
Printed by Agee the NC Bar Association

tJt\ I JUU t, J) tJVJ\JW L1U P t ./
This Document eRecorded: 10/26/2020 04:36:50 PM
Fee: $26.00 Tax: $250.00
Rockingham County, North Carolina
Benjamin J. Curtis, Register of Deeds
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: S250.00 Parcel Identifier No.: 132695
Mail after ret.-tnding to:Grantee(s)
This instrument was prepared by: Stegall&Clifford,PLLC,445 Dailey Madison Road,Suite 102,Greensboro,NC27410
Brief Description from the Index: Lot 59,Riverbend
THIS DEED made this 13 day of October,2020,by and between
GRANTOR GRANTEE
David Ray Case, Successor Trustee of Family Trust of Ray Martin D.Stull,11,unmarried
Arthur Case,dated October 19,2004 and Executor of the
Estate of Ray Arthur Cc"'(20 E 104) Property Address: 154 Woodlawn Drive,Stoneville,NC
27048
Mailing Address:12301 32nd Street
Sante Fe,TX 77510
The designation Grantor and Grantee as used herein shall include said parties,their heirs,successors,and assigns,and
shall include singular,plural,masculine,feminine or neuter as required by context.
W1T.NESSETH,that the Grantor,for a valuable consideration paid by the Grantee,the receipt of which is hereby
acknowledged,has and by these presents does grant,bargain,sell and convey unto the Grantee in fee simple,all that
certain lot or parcel of land situated in Mayo.City of Stoneville,Rockneham County,North Carolina and mare
particularly described as follows:
See Exhibit A'Attached Hereto and Made a Part Hereof
Is the property the primary residence of the Grantors?No
The property herein described was acquired by Grantor by instrument recorded in Book 1278,Page 1036,
•
Rockingham County Registry.
A map showing the above described property is recorded in Plat Book J,Page 29 and referenced within this -
instnnnent
. TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances thereto belonging
NC Br Asocirion Fe=Na 3 1976,Rcrisert_. inaaiu
Printed by Agreement with the NC Bar Association
Submitted electronically by "stegall & Clifford, PLLC"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Rockingham county Register of Deeds.
L

! i
SELLER DEBIT ' SELLER CREDIT GOVERNMENT RECORDING AND TRANSFER CHARGES BUYER DEBIT t BUYER CREDIT
-- ' 1 i '
; Recording Fees $91:10 1 "
„
—Deed:$26.00
—Mortgage:$64.00
- i---
E-Filing Fee to Stegall&Clifford Recording Account . $20.00
_ ..
- -- - -- ------ - -
$250.00 . Excise Tax(State Deed Taxes)to Stegall&Clifford Recording Account • -
Recording Fee-Certification of Trust to Stegall&Clifford Recording
531.00 .
' Account -
SELLER DEBIT SELLER CREDIT ' COMMISSIONS BUYER DEBIT i BUYER CREDIT
„.., , -: -- - ; • - . i —__ —
$3,750.00 - -!' listing Agent Commission to Garrett Group Real Estate : _ ,
- -------
-----. -_
$3,750.00 Selling Agent Commission to RE/MAX of Greensboro
; BUYER DEBIT BUYER CREDIT
SELLER DEBIT SELLER CREDIT l TITLE CHARGES
Title-Abstract or Title Search Fee to Stegall&Clifford,PLLC $175.00 1
Title-Courier Fee to Stegall&Clifford,PLLC $30.00
- ' - - - -
$407.-50'
- Title-Lender's-Coverage to Sterling Title Company .
i -
, Title-Owner's Coverage to Sterling Title Company $51.20
Title--Settlement or Attorney's Fee to Stegall&Clifford,PLLC . $750.00 •
I ,
SELLER DEBIT I SELLER CREDIT MISCELLANEOUS CHARGES I BUYER DEBIT j BUYER CREDIT
1 .._:- . .._ .. .. .
$250.001 1 Document Preparation Fee to Ste-gall&Clifford,PLLC .
$50.00 , - Payoff Delivery Fee to Stegall&Clifford,PLLC , : _ - _.
-- --- - -- —
$50.00' Proceeds Delivery Fee to Stegall&Clifford,PLLC
,Transaction Fee to RE/MAX of Greensboro , $HOITO
-- -- -- - ---
- - - -- --- 1-- --- ---- --- --- ''
Homeowner's Insurance Premium to Allstate Insurance Company ; $690.00 _
, .
• BUYER DEBIT BUYER CREDIT
SELLER DEBIT I SELLER CREDIT ;TOTALS,
,. ----
$106,38126 i $125,132.39 $130,630.71 $116,932.50
;
7,,.7--;,---5,,,--,77-24,--',:cTii:-=,i--,.:Q---•-•zr--
CASH FROM BUYER -:fz----:$169821 =r
t.,-;;,-1.:',--i;: -1,,-.'--,:.1-_-:--:.- 4-•:.'-:
.,:-.,:-.‘--, ..--_,-, ---.=:--, -;,,-
CASH TO SELLER ii$Yg#512A:8 ---
Acknowledgement
Wert have carefuRy reviewed this settlement statement and had it to be a true and accurate statesmen/of ell recetits and dbursement made on my
account or by me in this transaction and further certify that lime recdved a copy of this settlement statement
Weil authorize Steger/&Miami.PLLC to cause the hands to be disbursed in accordance with this siaeiuenL
Buyer Setter •
•._ ).- _ _ /01....2„4/120,WantaY TrUSE of Ray Arthur Czae
Alk.ti,4 D. il Date
BY' 41, A gs cve qvgav
David Ray Case.Tr age
Settlement Agency
. ---2------ (9/Zift7--a
Agrsd
5 of 5 10/23120,1:21 PP
si

Settlement Statement
- Your Order Summary
ME;- -" "• STULL-CASE_- - ' =_ PRoa fY�S_ 5 � . a�a _ -- 100256,0E -
• e.s
-___u .__-PREPARED__- 1-- --- '_,_ = _ ---- - - - StuA,iI — — - _
Tr�®sr 5t2�&CIsllaad.PLlC
_ "_" _,._ - -- .-_ - - _ -u�ax _: � -----�� aid
=-----__--= 10/26/O2 , -- BUYER Box -
10/26/2020:- :-- ,-. ,- PO 163- 445 DoFey
-"SEPfI.L"dE[Srj - Rdlincre,NY 14735 - _OUR ADDRESS Stine 102-
_"DISBUREEMfNr-. ' -' 10/26/2020 -- -_ =-L - _` D Ca fm - - _- - - = __-.--_.
-- -, 281-311
- - - a OUR Y_T (3363 0__ ' - -
SE7TLEMo17 tookilON -445 Dailey Madsen Roa-- =SEaLER - --- -Cam" . ---- --
- -Seite102 - - -- " - 1230132ndStreet: - CflCCD-- Lautee5tegaH
Greensboro,NG 27410 -- - -" -- -"Sanee Fe,IX 77510 -
- - _ Gtizenis Bank NA - - -
ISADA/AIWA - - -
- -- - PO Brno 202060 -
- - FloncerSC-295022060 -- _ - - -
Charges -
SELLER DEBIT " SELLER CREDIT = PRIMARY CHARGES&CREDITS BUYER DEBIT i, BUYER CREDIT
$125,000-00 ' Sales Price of Property $125, .00 •
Deposit
----_ $112,500.00
Loan Amount
$2,5p0,00 Seller Credit $2,500.00
_ - -
Lender Credit
; BUYER DEBIT BUYER CREDIT
SELLER DEBIT . SELLER CREDIT PRORATIONS/ADJUSTMENTS
— -
i $132.39 I County Taxes 10/26/2020 to 12/31/2020 $13239 .
$800.00. Due Diligence Fee $800.00
SELLER DEBIT SELLER CREDIT i LOAN CHARGES BUYER DEBIT 9 BUYER CREDIT
1.652%of Loan Amount(Points) _ $1. 58.50
- Appraisal"Fee to Jefferson Capital $505.00
---------------2Credit Report Fee to Advantage Credit $3L�
' -- _ "VOE Fee(3rd Party)to Jefferson Capital - $48.95 .
Prepaid Interest($8.86 per day from 10/26/2020 to 11/01/2020) $53.17
I BUYER DEBIT = BUYER CREDIT
SELLER DEBIT SELLER CREDIT IMPOUNDS
Homeowner's insurance$5750 per month for 3 mo. $17250 i
— ~—W W Property taxes$60.85 per month for 2 mo. $12170
-� - Aggregate adjustment - - - $5750
SELLER DEBIT SELLER CREDIT ' PAYOFFS -} f BUYER DEBIT : BUYER CREDIT
$94,75A26 i ; Payoff to Flagstar Banc,Fsb . '-
Principal:$94,646.26
—_. - '-— Interest:$44.00
--—_. -- Fax Fee $60.00

United States Environmental Protection Agency Form Approved.
EPA Washington,D_C 2046D OMB No.2040-005T
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
2 t 3 I NCG550112 111 121 21/09/20 117 18121 191 S t 2011
2111 I , I I I 1 1 111 1 1 I 1 I 1 1 I I I I I 1 I 1 1 I I I I II 11 1 1 1 168
Inspection Work Days Facility Self-Monitoring Evaluation Rating B1 QA Reserves! 1
671 701 1 711 1 72 1 ,y ! 731 I 174 791 1 1 1 1 1 1 180
l 1 Sewn B:Facility Data Li
1 J 4
Name and Location of Facility Inspected(For Industrial Users discharging to POTW,also indude Entry Tune/Date Permit Effective Date
POTW name and NPDES permit Number) 01:3OPM 21/09/20 • 20/11/24
154 Woodlawn Drive
154 Woodlawn Dr Exit Tune/Daie Permit Expiration Date
02:OOPM 21/09/20 25/10/31
Stoneville NC 27046
Name(s)of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s) Other Facility Data
(t/
Name,Address of Responsible Official/Title/Phone and Fax Number
Contacted
Ray A Case,154 Woodtawn Dr Stoneville NC 27048///
No -
Section C:Areas Evaluated During Inspection(Check only those areas evaluated)
II Operations&Maintenar Records/Reports Facility Site Review II Effluent/Receiving Wale
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
Jordan Burbage DVViZ/4IVSR0 WQ/336-776-9697/ 9/29/2021
8a4.
—36cAF656CD3S4EF_.
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
,--- a
10j8/202I
T.
L-145a613e225c94FA._.
EPA Form 3560-3(Rev 9-94)Previous editions are obsolete.
Page 1

NPDES yr/rno/day Inspection Type
NCG550112 111 121 21/0820 117 18
Section D:Summary of FindinglComments(Attach additional sheets of narrative and checklists as nerc sary)
Owner on permit deceased years ago. House has been vacant. This according to brand new
homeowner.
Homeowner unaware of septic system.Walked her through the overview and provided disinfection
tablet educational pamphlet. Encouraged her to look into local septic pumping service.
Location of septic tank, sand filter, and discharge pipe unknown. Chlorinator tubes were located-dry
soil at bottom.
Page# 2

Permit: NCG550112 Owner-Facility: 154 Vtfoodtavrn Drive
Inspection Date: 09/20/2021 Inspection Type: Compliance Evaluation
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? • ❑ 0 ❑
Does the facility analyze process control parameters,for ex MLSS, MCRT, Settleable ❑ ❑ I El
Solids, pH, DO, Sludge Judge, and other that are applicable?
Comment: New owner unaware of system.
Effluent Pipe Yes No NA NE
Is right of way to the outfall properly maintained? ❑ • El ❑
Are the receiving water free of foam other than trace amounts and other debris? 111 ❑ El ❑
• If effluent (diffuser pipes are required) are they operating properly? El El • El
Comment Unable to locate discharge pipe.
Septic Tank Yes No NA NE
(If pumps are used) Is an audible and visual alarm operational? ❑ El II El
Is septic tank pumped on a schedule? ❑ • ❑ El
Are pumps or syphons operating properly? El El • El
Are high and low water alarms operating properly? El 0 • 0
Comment No idea when last pumped.
Sand Filters (Low rate) Yes No NA NE
(If pumps are used) Is an audible and visible alarm Present and operational? El ❑ 11 ❑
Is the distribution box level and watertight? ❑ ❑ E ❑
Is sand filter free of ponding? 0 0 II ❑
Is the sand filter effluent re-circulated at a valid ratio? ❑ El U ❑
#Is the sand filter surface free of algae or excessive vegetation? ❑ ❑ N ❑
#Is the sand filter effluent re-circulated at a valid ratio? (Approximately 3 to 1) ❑ ❑ II El
Comment:
Disinfection-Tablet Yes No NA NE
Are tablet chlorinators operational? • ❑ ❑ ❑
Are the tablets the proper size and type? ❑ El ❑ MI
Number of tubes in use? 2
Is the level of chlorine residual acceptable? ❑ ❑ El MI
Is the contact chamber free of growth, or sludge buildup? • 0 0 ❑
Page# 3

Permit NCG550112 Owner-Facility: 154 Woodiawn Drive
Inspection Date: 09/20/2021 Inspection Type: Compliance Evaluation
Disinfection-Tablet Yes No NA NE
Is there chlorine residual prior to de-chlorination ❑ ❑ ❑ II
Comment: Dry soil visible at bottom of chlorinator tubes.
Page# 4
a