NCG550060_Compliance Evaluation Inspection_20240208

North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
October 26th, 2010
Jason Jurkowich, Owner
130 Roswell Drive
Kernersville, NC 27284
Subject: Compliance Evaluation
NPDES General Wastewater Discharge Permit— NC550000
Certificate of Coverage NCG550060
Single Family Residence 3211 Broadview Drive, Pfafftown, NC 27040
Forsyth County
Dear Mr. Jurkowich:
Mr. Ron Boone, of the Winston-Salem Regional Office of the North Carolina Division of Water Quality
(DWQ or the Division), conducted a compliance evaluation inspection (CEI) of your single family
residence wastewater treatment system located at 130 Roswell Drive, in Kernersville, Forsyth
County, North Carolina, on October 15th, 2010. Your assistance and cooperation was greatly
appreciated. Inspection findings are summarized below and an inspection report is attached for your
records.
According to Forsyth County tax records, you took ownership of the property in January, 2007.
There were no records available at the time of the inspection, including blueprint drawings,
maintenance records, records of the septic tank being pumped, effluent analytical records, etc. Mr.
Boone advised you to start keeping all records as required by the permit.
Mr. Boone could not locate the chlorinator or the discharge pipe. The stream did not exhibit
any adverse conditions that may have been attributed to the discharge. No samples were taken
however.
Please continue to search for original record drawings and other records that may assist you in
locating the chlorinator and discharge pipe and notify this office if and when you do locate either. The
Forsyth County Health Department may be able to assist you in finding original record drawings for
the property. You may also contact them through their website. Attached is a copy of the general
permit, its technical bulletin, and a list of chlorine suppliers.
Mr. Boone also gave you a Name/Ownership Change form during the inspection. Please fill
out the form completely and send it to the address located on the bottom of the second page. Failure
to do so by November 15th will result in this office taking further action.
North Carolina Division of Water Quality,Winston-Salem Regional Office
Location:585 Waughtown St.Winston-Salem,North Carolina 27107 One
Phone:[phone]\FAX:[phone] Customer Service:1-877-623-6748 NorthCarolina
Internet:www.ncwaterquality.org \at ra//
An Equal Opportunity\Affirmative Action Employer d

Jason Jurkowich
130 Roswell Drive,NCG550060
Compliance Evaluation Inspection
October 26,2010
Page 2
Thank you again for you assistance and cooperation in this matter. Please do not hesitate to
contact Mr. Boone or me if you have any questions regarding the inspection, this letter, or the permit,
at 336-771-5000.
Sincerely,
11(
Steve W. Tedder
Water Quality Regional Supervisor
Winston-Salem Region
Division of Water Quality
Attachments:
1. BIMS Inspection Report
2. NCG550000 General Permit
3. NCG550000 Technical Bulletin
4. List of Chlorine Suppliers
5. Name/Ownership Change Form
cc: WSRO — SWP
Central Files
N_PDES West-Unit, Charles Weaver )

ri
United States Environmental Protection Agency
EPAWashington,D.C.20460 Form Approved.
r�'1 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 2 151 31_ NCG550060 111 12I 10/10/15 117 181 CI 191 SI 20I II
Remarks
21IIII I1I11II111II II 1 I I I I I I I I I IIIIIIIIIIIIIIII11166
Inspection Work Days Facility Self-Monitoring Evaluation Rating B1 QA --- Reserved-------- -
67I 169 701 I 711 I 72 I N I 731 I l 74 751 I I I I I I 180
Section B: Facility Data
Name and Location of Facility Inspected(For Industrial Users discharging to PO7W,also include Entry Time/Date Permit Effective Date
POTW name and NPDES permit Number).
04:30 PM 10/10/15 06/08/02
130 Roswell Drive
130 Roswell Dr Exit Time/Date Permit Expiration Date
Kernersville NC 27284 05:00 PM 10/10/15 07/07/31
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
Barbara Little,3993 Queens Grant Ct High Point NC 272657916/// No
Section C: Areas Evaluated During Inspection(Check only those areas evaluated)
Permit
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//704-663-1699 Ext.2202/
�6 2_ 6/20 /
Signature of Management;AReviewer Agency/Office/Phone and Fax Numbers Date
tt-9:-(44" I0 — 926 'le
EPA Form 3560-3(Rev 9-94)Previous editions are obsolete
Page# 1

NPDES yr/mo/day Inspection Type 1
31 NCG550060 1
11 121
10/10/15 117 18ICI
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

Permit: NCG550060 Owner-Facility: 130 Roswell Drive
Inspection Date: 10/15/2010 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? ®
0
Is the facility as described in the permit? n ■ ❑ ❑
#Are there any special conditions for the permit? ❑ ® ❑ ❑
Is access to the plant site restricted to the general public? ❑ ❑ is ❑
Is the inspector granted access to all areas for inspection? ■ ❑ ❑ n
Comment: Please refer to the attached inspection summary letter.
Page# 3