NCG550058_Compliance Evaluation Inspection_20120113

A •.4,
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P. E. Dee Freeman
Governor Director Secretary
January 13, 2012
Ms. Vickie Rivers
4669 Paula Drive
Winston-Salem, NC 27127
Subject: Compliance Evaluation Inspection
NPDES General Wastewater Permit NCG550000
Certificate of Coverage: NCG550058
4669 Paula Drive, Winston-Salem
Forsyth County
Dear Ms. Rivers:
Ron Boone, of the NC Division of Water Quality (DWQ), Winston Salem Regional
Office (WSRO), conducted a compliance evaluation inspection of your single family
residence wastewater treatment system located at 4669 Paula Drive, in Winston-Salem,
Forsyth County, NC, on January 12, 2012. Your assistance and cooperation during the
inspection was greatly helpful and appreciated. The findings of the inspection are
summarized below and an inspection report is attached for your records.
Your single family residence wastewater treatment system is regulated under NC
NPDES General Wastewater Permit NCG550000 and has been issued certificate of
coverage (COC) number NCG550058. The system discharges to an unnamed tributary
to South Fork Muddy Creek, which is currently classified as Class C waters and is
located in the Yadkin Pee Dee river basin.
Your system consists of a septic tank, filter field and a chlorinator. You told Mr.
Boone that you last had the tank pumped approximately three years ago, although
records were not immediately available during the inspection. You are reminded to
have the tank pumped every three to five years in order to help keep the system in top
operating condition at all times.
There were no signs of system failure during the inspection. You were able to
show Mr. Boone the approximate location of the discharge pipe but it could not be
exactly located because of heavy overgrowth. There were no signs of any adverse
1617 Mail Service Center,Raleigh,North Carolina 27699-1617
Location:512 N.Salisbury St.Raleigh,North Carolina 27604
Phone:[phone] FAX:[phone]
Internet:www.ncwateraualitv.orq One
An Equal Opportunity\Affirmative Action Employer NorthCarolina
Naturally

Vickie Rivers
4669 Paula Drive,Winston Salem
NCG550058
January 13,2012,Page 2 of 2
effects of the discharge on the receiving stream. Samples of the discharge have not
been taken. All annual fees have been paid and the permit is current and up to date.
Please note the chlorinator could not be located during the inspection. This
system was originally built with a chlorinator. You are highly advised to locate the
chlorinator and begin to use it as it is intended. If the chlorinator cannot be located or
has been removed, then a new chlorinator unit should be installed. Please contact Mr.
Boone if you have any questions regarding this issue.
It is also noted that William Rivers has passed and that you are the rightful heir to
the property. Therefore, the name on the permit should be changed to yours. Attached
to this letter is a Permit Renewal form that has been filled out with the appropriate
information. All you have to do is sign and date the form and mail it to the address
located on the bottom of the second page. This should be sufficient to have the name
on the permit changed to yours.
If you have any questions or future problems with the system, please do not
hesitate to contact us. You can call me or Mr. Boone at 336-771-5000. Also, our email
addresses are corey.basinder a(�ncdenr.gov and ron.boone [e-mail], respectively.
Sincerely,
�Uu ct\ �r
\f, W. Corey Basinger
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality
Attachments:
1. Inspection Report
2. Filled Out Permit Renewal Form
CC:
1. WSRO/SWP Files
2. Central Office
3. NPDES Unit

I
United States Environmental Protection Agency Form Approved.
E PA 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 IL 31 NCG550058 111 121 12/01/12 117 18I C I 19I S I 201
Remarks
211111IIIIIIIillIIIIII1111IIIIIIIIIIII IIII IIIIIII66
Inspection Work Days Facility Self-Monitoring Evaluation Rating B1 QA Reserved
671 169 70I I 711 I 72I N I 731 I 174 751 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 Entry Time/Date Permit Effective Date
POTW name and NPDES permit Number)
02:00 PM 12/01/12 07/08/01
4669 Paula Drive
4669 Paula Dr Exit Time/Date Permit Expiration Date
Winston Salem NC 27127 02:30 PM 12/01/12 12/07/31
Name(s)of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s) Other Facility Data
ul
Name,Address of Responsible Official/Title/Phone and Fax Number
Contacted
William S Rivers,4669 Paula Dr Winston Salem NC 27127/// No
Section C: Areas Evaluated During Inspection(Check only those areas evaluated)
Permit •Facility Site Review El 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
Ron Boone WSRO WQ//336-771-4967/ /
j c �� C I//:.�/ �.<.3iZ
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
PForm (Rev 9-94)Previous editions are ob�5olete.
EPA 3560 3
Page# 1

NPDES yr/mo/day Inspection Type
31 NCG550058 111 121 12/01/12 I 17 18Id
Section D: Summary of Finding/Comments(Attach additional sheets of narrative and checklists as necessary)
Please refer to the attached inspection summary letter.
Page# 2

I
Permit: NCG550058 Owner-Facility: 4669 Paula Drive
Inspection Date: 01/12/2012 Inspection Type: Compliance Evaluation
Permit Yes No NA NE
(If the present permit expires in 6 months or less). Has the permittee submitted a new application? nnion
Is the facility as described in the permit? n n ■ n
#Are there any special conditions for the permit? n ■ n n
Is access to the plant site restricted to the general public? ■ n n n
Is the inspector granted access to all areas for inspection? ■ n n n
Comment: None
Effluent Pipe Yes No NA NE
Is right of way to the outfall properly maintained? norm
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: None
Page# 3

A . .Ai Division of Water Quality/Water Quality Section
t
NCDENRNational Pollutant Discharge Elimination System
NORTH CAROLINA CEPARTMENT OF
ENVIRONMENT AND NI/TURN-RESOURCE°_ NC G` 0000
RENEWAL FORM FOR EXISTING PERMITTED FACILITIES
NPDES renewal application for continued coverage under General Permit NCG550000:
Certificate of Coverage NCG550058
(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 Vickie Rivers
Street Address 4669 Paula Drive
City Winston Salem
Telephone (Home) (Mobile) 336 _ 354-9669
(e-mail address) [e-mail]
*Address to which all permit correspondence will be mailed
2) Location of facility producing discharge*:
Street Address 4669 Paula Drive
City: Winston Salem
County Forsyth
Telephone (Home) _ (Mobile) 336 _ 354-9669
* 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:
;El.Septic tank 0 Dosing tank rg Primary sand filter 0 Secondary sand filter
❑ Recirculating sand filter(s) ® Chlorination 0 Dechlorination
❑ Other form of disinfection: 0 Post Aeration(describe)
5) Other Information:
a) When was the septic tank last pumped out?About three years ago
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?Year-round
c) Approximately how many people use the facility when it is occupied?2
d) When was the wastewater system installed?Approximately March, 1976
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:Vickie Rivers
(Signature of Applicant) (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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