NCG550059_Compliance Evaluation Inspection_20151005

NCDENR
North Carolina Department of Environmental Quality
Pat McCrory Donald R. van der Vaart
Governor Secretary
September 28, 2015
Juli Cservenko
4663 Paula Drive
Winston-Salem, NC 27127
Subject: Compliance Evaluation Inspection
Permittee: Juli Cservenko, Owner
Facility: 4663 Paula Drive, Clemmons, NC 27127 RECEIVED/DENR/DWR
Permit: NCG550000 General Wastewater Permit
Certificate of Coverage: NCG550059 O(.,T = ?015
Forsyth County
Water Quality
Dear Ms. Cservenko: Permitting Section
1. Ron Boone, of the Winston Salem Regional Office (WSRO) of the NC Division of Water Resources
(DWR or the Division), conducted a compliance evaluation inspection of the single family wastewater
system at your place of residence on September 22, 2015. Your assistance and cooperation was greatly
appreciated. An inspection checklist is attached for your records and inspection findings are detailed
below.
2. The State requires the Division to inspect these types of systems every five years. Your system was last
inspected in July, 2010.
3. The wastewater system at your residence appears to operating properly. Mr. Boone found no
discrepancies or problems that indicated anything was wrong.
4. At this point it is probably most prudent that you have the septic tank pumped at least every three years
(with four people in the residence). Please keep records of septic tank pumping on hand as a historical
record and proof that you had the tank pumped. The permit does require that you have the tank pumped
as required.
5, You were not aware of the effluent water ever having been tested by a laboratory. This is also a
requirement of the permit, to have the effluent water tested once per year. You can contact a local
commercial laboratory and inquire as to whether they can perform the testing required by the permit.
Please refer to the copy of the permit attached to this letter.
6. The chlorinator did not have chlorine in it at the time of the inspection. Please acquire chlorine tablets
and begin placing them in the chlorinator as needed.
7. Your husband, Mike Cservenko, who is currently the owner of the residence according to our records,
has passed away and you are now the owner. Also attached to this letter is a Name/Ownership Change
Request form. It has been mostly filled out for you, but please,fill in your phone number and email
450 West Hanes Mill Road,Suite#300,Winstdn-Salem,Ndrth Carolina 27105
Phone:[phone]\Internet:www.ncdenr.gov
An Equal Opportunity 1 Affirmative Action Employer—Made in part by recycled paper

address in Section III, Application Information. Once completely filled out, please send it to the address
indicated on the form. Please be aware that the permit fee has not been paid for six years. The permit
fee is $60.00 per year, so a total of $360.00 is needed to bring the permit up to date. However, it is
unknown whether you will be required to pay all of this. You will be billed at some point in the future.
8. Please keep this letter with your records for the system along with copies of invoices from the Division
for the annual permit fee, the Certificate of Coverage, records of septic tank pumping, maintenance and
repair records, etc.
9. These types of systems should be inspected at least every five years to ensure they're properly
operated and maintained. Failure to properly operate and maintain the system can result in expensive
repair costs as well as failure of the system to properly treat the wastewater. Also, you need to have
your septic tank pumped once every three to five years, depending on usage.
10. If you have any questions regarding this letter or the NCG550000 general permit, please don't hesitate
to contact us at 336-776-9800.
Sincerely,
Y
U W. Corey Basinger
Regional Supervisor
Water Quality Regional Operations
Division of Water Resources
Attachments:
1. Inspection Report
2. Copy of latest Certificate of Coverage NCG550083
3. Copy of NCG550000
4. Technical Bulletin
5. Name/Ownership Change Request
CC: WSRO Files
Central Files
NPDES Unit
- J

f
United States Environmental Protection Agency Form Approved.
EPAWashington,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 ��, 2 L 3 I NCG550059 111 121 15/09/22 117
18 Lin 19 [ 2 201 I
21I 1 1 1 1 1 I I I I I I I I L I I I I I I I I I 1 1 I I I i l I i I I I I I 1 I I I r6
Inspection Work Days Facility Self-Monitoring Evaluation Rating B1 QA Reserved
67 I I 70 I I 71 I I 72 L—I I N I 'I I 174 711 I I I I I 1l80
Section B: Facility Data 1
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) 10:00AM 15/09/22 09/04/06
4663 Paula Drive
Exit Time/Date Permit Expiration Date
4663 Paula Dr
11:00AM 15/09/22 12/07/31
Winston Salem NC 27127
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
Mike Cservenko,4663 Paula Dr Winston Salem NC 271 27//3 36-72 0-21 97/
No
Section C:Areas Evaluated During Inspection(Check only those areas evaluated)
El Other
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//336-776-9690/
9/2—CAC-
-cam
Signature f Management Q A R viewer Agency/Office/Phone and Fax Numbers Date
7/agfis
EPA Form 3560-3(Rev 9-94)Previous editions are obsolete.
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NPDES yr/mo/day Inspection Type 1
31 NCG550059 I11 121 15/09/22 I 17 18 I,.
Section D:Summary of Finding/Comments(Attach additional sheets of narrative and checklists as necessary)
Location of septic tank unknown.
Last time septic tank was pumped unknown, but a long time ago.
With four people living in the residence, the pump should be pumped out once every three years.
Chlorinator was located during inspection but there was no chlorine in it.
Ms. Cservenko not aware of requirement to put chlorine in the chlorinator.
Discharge pipe could not be located during inspection.
Large wet spot on north end of house. Looks to be a potable water leak.
Effluent never tested before.
Page# 2

Permit: NCG550059 Owner-Facility: 4663 Paula Drive
Inspection Date: 09/22/2015 Inspection Type: Compliance Evaluation
Other Yes No NA NE
Comment: None
Page# 3