NCG550060_Permit (Issuance)_20170217

ROY COOPER
T Governor
•
MICHAEL S. REGAN
Secretary
Water Resources
ENVIRONMENTAL QUALITY S. JAY ZIMMERMAN
Director
February 17, 2017
Mr.Jason Jurkowich
130 Roswell Drive
Kernersville, NC 27284
Subject: General Permit NCG550000
130 Roswell Drive
Certificate of Coverage NCG550060
Forsyth County
Dear Permittee:
The Division has received and approved your request to transfer ownership of the subject Certificate
of Coverage (CoC)under General Permit NCG550000. As a result, the Division hereby reissues NCG550060.
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 any other State, Federal, or Local
governmental permit that may be required. If you have any questions concerning the requirements of the
General Permit, please contact Brianna Young of the NPDES staff[919-807-6388 or
[e-mail]].
erely,
for S.Jay Zimmerman, P. .
Director, Division of Water Resources
cc: Winston-Salem Regional Office
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh,NC 27699-1617
919 807 6300 919-807-6389 FAX
hugs://deq.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/npdes-wastewater-permits

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
GENERAL PERMIT NCG550000
CERTIFICATE OF COVERAGE NCG550060
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,
Jason Jurkowich
is hereby authorized to discharge <1000 gallons per day of domestic wastewater from a
facility located at
130 Roswell Drive
Kernersville
Forsyth County
to receiving waters designated as an unnamed tributary to Belews Creek, a class C stream in
subbasin 03-02-01 of the Roanoke River Basin in accordance with the effluent limitations,
monitoring requirements, and other conditions set forth in Parts I, II, and III hereof.
This certificate of coverage takes effect February 17, 2017.
This Certificate of Coverage shall remain valid for the duration of the General Permit.
Signed this day February 17, 2017.
•
forAle;Zimmerman, P.G.
irector, Division of Water Resources
By Authority of the Environmental Management Commission

A774,
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory Thomas A. Reeder John E.Skvarla, Ill
Governor Director Secretary
NOTICE OF RENEWAL INTENT
Application for renewal of existing coverage under General Permit NCG550000
Existing Certificate of Coverage(CoC): NCG550 r)l 0 RECEIV
t:Q/D Rip
(Please print or type)
DEC 0 9 2016
1) Mailing address of property owner: (address to which all correspondence should be mail
ed, ' �r na s
� f
Ion
Owner Name rU U OCr 1 '
Street Address (?C ibc)w?fI 1 r-
City Ve,j:AMA_ State ,ti( ZIP Code 11i286-1
Telephone# Cell# 3(' �Gf O L-113
Fax# l
Email Address ('\G�J r\C� r,{ n^Gk,1,1 GC
2) Location of facility producing discharge: Of facility is not yet constructed, give street address or lot#)
Street Address 00, j2G,c. >e)I o r
City Ketin ((t State ,A-1( ZIP Code 27--)
County S9'f
Telephone# Cell# '336 24/ o�q- 3
3) Description of Discharge:
a) Is the discharge from (check what applies):
t 4em�mary Residence
❑ Vacation/Second Home
❑ Undeveloped Property
❑ Other(describe):
4) Please check the components that comprise the wastewater treatment system:
❑ Septic Tank o Dosing Tank o/lrimary Sand Filter ❑ Secondary Sand Filter
❑ Recirculating Sand Filters ©''Chlorination ❑ Dechlorination ❑ Other Form of Disinfection
❑ Post Aeration(describe):
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NCG500000 Renewal fpplication
5) Other Information:
a) When was the septic tank last pumped out?
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? E 'YearRound ElSeasonal
c) Approximately how many people use the facility when it is occupied? 3
d) When was the wastewater system installed? .
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.
Printe . e of Person Signing: f#S Jl,l'r?ICOLc1 11
(SignatureofApplicant) (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.)
This Notice of Renewal Intent does NOT require a separate fee.
The permitted facility already pays an annual fee for coverage under NCG550000.
♦ ♦ ♦
Mail this application, one copy of the entire package and a copy of the receipt for your last septic
service to:
NC DENR/DWR/Water Quality Permitting Section
1617 Mail Service Center
Raleigh,North Carolina 27699-1617
Attn: Charles Weaver
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