NCG550054_Permit (Issuance)_20090423

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North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue,Governor Coleen H. Sullins, Director Dee Freeman,Secretary
April 23, 2009
Henry O.Washington
4670 Duffer Ln
Pfafftown, NC 27040
Subject: Renewal of coverage/General Permit NCG550000
504 Gayron Drive
Certificate of Coverage NCG550054
Forsyth County
Dear Permittee:
In accordance with your renewal application [received on April 21, 2009], the Division is renewing
Certificate of Coverage (CoC) NCG550054 to discharge under NCG550000. This CoC is issued pursuant to
the requirements of North Carolina General Statue 143-215.1 and the Memorandum of Agreement between
North Carolina and the US Environmental Protection agency dated October 15, 2007 [or as subsequently
amended].
If any parts, measurement frequencies or sampling requirements contained in this General Permit
are unacceptable to you, you have the right to request an individual permit by submitting an individual
permit application. Unless such demand is made, the certificate of coverage shall be final and binding.
Please take notice that this Certificate of Coverage is not transferable except after notice to the
Division. The Division may require modification or revocation and reissuance of the certificate of coverage.
Contact the Winston-Salem Regional Office prior to any sale or transfer of the permitted facility.
Regional Office staff will assist you in documenting the transfer of this CoC.
This permit does not affect the legal requirements to obtain other permits which may be required by
the Division of Water Quality or permits required by the Division of Land Resources, Coastal Area
Management Act or any other Federal or Local governmental permit that may be required.
If you have any questions concerning the requirements of the General Permit, please contact Charles
Weaver of the NPDES staff[919 807-6391 or [e-mail]].
Sincerely,
c.):01/1
leen H. Sullins
cc: Central Files
Winston-Salem Regional Office/Surface Water Protection •
NPDES file
1617 Mail Service Center,Raleigh,North Carolina 27699-1617 One
512 North Salisbury Street,Raleigh,North Carolina 27604 NorthCarolina
Phone: [phone]/FAX [phone]/Internet:www.ncwaterquality.org Naturally •
An Equal Opportunity/Affirmative Action Employer-50%Recycled/10%Post Consumer Paper

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NCG550000
CERTIFICATE OF COVERAGE NCG550054
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,
Henry O. Washington
is hereby authorized to discharge domestic wastewater [450 GPD] from a facility located at
504 Gayron Drive
Winston-Salem
Forsyth County
to receiving waters designated as an unnamed tributary to Mill Creek, a class C stream in
subbasin 03-07-04 of the Yadkin-Pee Dee River Basin in accordance with the effluent limitations,
monitoring requirements, and other conditions set forth in Parts I, II, III and IV hereof.
This certificate of coverage shall become effective April 23, 2009.
This Certificate of Coverage shall expire on July 31, 2012.
Signed this day April 23, 2009.
.. L414 et,11,4,14.
for to een H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission
.

FOR AGENCY USE ONLY
Date Received
Year Month Day
' Division of Water Quality/Water Quality Section
Certificate of Coverage
NCDE R National Pollutant Discharge Elimination System N CIG I I
N g y Check# Amount
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES NCG550000 Permit Assigned to
RENEWAL FORM FOR EXISTING PERMITTED FACILITIES
NPDES renewal application for continued coverage under General Permit NCG550000:
Certificate of Coverage NCG556(�jt
(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 f--jt N 2 Q lj/a s h I N O /ki
Street Address 7C l D U{24Te /Z L'N.
City pf pc-1 O(c) 7 O '/a
Telephone (Home),33C t7 /c2 (Mobile)
(e-mail address) RECEIVE-D
*Address to which all permit correspondence will be mailed
2) Location of facility producing discharge*: APR 2 1 2009
Street Address 50'/ c'%y,e.oN D'Z DENR - WATER QUALITY
City: A,i/IV 5 TVA/ S A/E/v\ POINT SOURCE BRANCH
County rQ2 5 YrF/
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):
:A 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:
2 eptic tank 0 Dosing tank 0 Primary sand filter Pl Secondary sand filter
0 Recirculating sand filter(s) 0 Chlorination 0 Dechlorination
0 Other form of disinfection: 0 Post Aeration(describe)
5) Other Information:
a) When was the septic tank last pumped out? yE ta�S
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? yr./- PL.-/\4t/NG(
c) Approximately how many people use the facility when it is occupied? -3
d) When was the wastewater system installed?
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: nLrrlre.r C fAJI Sjt i N/6 Td iv
4/17/ q
(Signature of Applicant) /c— (Date Signed)
North Carolina General Statute 143-215.6 b (i)provides that:
Any person who knowingly makes any false statement, representation, or certification in any
application, record, report, plan or other document filed or required to be maintained under Article
21 or regulations of the Environmental Management Commission implementing that Article, or who
falsifies, tampers with or knowingly renders inaccurate any recording or monitoring device or
method required to be operated or maintained under Article 21 or regulations of the Environmental
Management Commission implementing that Article, shall be guilty of a misdemeanor punishable
by a fine not to exceed$25,000, or by imprisonment not to exceed six months, or by both. (18 U.S.C.
Section 1001 provides a punishment by a fine of not more than $25,000 or imprisonment not more
than 5 years, or both,for a similar offense.)
Mail this completed form and a copy of the receipt for your last septic service to:
Mr. Charles H. Weaver, Jr.
NC DENR/DWQ/NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
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