NCG550080_Permit (Issuance)_20090528

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ATA,
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue,Governor • Coleen H. Sullins, Director Dee Freeman, Secretary
May 28, 2009
Eric Fields
1009 Augusta Court
Kernersville, NC 27284-9269
Subject: Renewal of coverage/General Permit NCG550000
1009 Augusta Court
Certificate of Coverage NCG550080
Forsyth County
Dear Permittee:
In accordance with your renewal application[received on May 27, 2009],the Division is renewing
Certificate of Coverage (CoC)NCG550080 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,
or Coleen H.Sullins
cc: Central Files
Winston-Salem Regional Office/Surface Water Protection
ODE ale
1617 Mail Service Center,Raleigh,North Carolina 27699-1617 One
512 North Salisbury Street,Raleigh,North Carolina 27604 NorthCarolina.
Phone: [phone] I FAX [phone] I Intemet:www.ncwaterquality.org^ •NR'tuNail

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STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
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GENERAL PERMIT NCG550000
CERTIFICATE OF COVERAGE NCG550080
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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,
•
Eric Fields
is hereby authorized to discharge domestic wastewater [750 GPD] from a facility located at
1009 Augusta Court
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, III and IV hereof.
This certificate of coverage shall become effective May 28, 2009.
This Certificate of Coverage shall expire on July 31, 2012.
Signed this day May 28, 2009
14/1 61114(
fo een H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission

• FOR AGENCY USE ONLY
Date Received
Year Month Day
A71191:61,
• Division of Water Quality/Water Quality Section
Certificate of Covers e
N CDENR National Pollutant Discharge Elimination System N ck
g y Check# Amount
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES Permit Assigned to
NCG550000
RENEWAL FORM FOR EXISTING PERMITTED FACILITIES
NPDES renewal application for continued coverage under General Permit NCG550000:
Certificate of Coverage NCG55 0060
(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 1 fJ
• Street Address /0 Q 9 A-u',
City ,�
Telephone (Home) 70 Ja q ?oh c/ (Mobile) 3-3 4 a t 0 93—7/
(e-mail address) e P7 e id-t G ,—L', d G o nA
*Address to which all permit correspondence will be mailed
2) Location of facility producing discharge*:
Street Address /0 0 9 , ki g /f 4a— C
City: l��.—e..vJ Vif(L
County
Telephone (Home) _ 336 '/ q LOLL/ (Mobile) 3)G. z/0 9J 3 7
* 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): Ec E NED
A. Primary residence
❑ Vacation/second home MAY 2 7 2009
❑ Undeveloped property
❑ Other [describe]: DENR - WATER QUALITY
POINT SOURCE BRANCH
Page 1 of 2

NCG550000 renewal form
4) Please check the components that comprise the wastewater treatment system:
❑ Septic tank ❑ Dosinglank ❑ Primary sand filter 0 Secondary sand filter
❑ Recirculating sand filter(s) ❑ Chlorination ❑ Dechlorination
❑ Other form of disinfection: ❑ Post Aeration(describe)
5) Other Information:
a) When was the septic tank last pumped out? yf�f� _/,,_ -C1 7
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? � �� �� Va''`'-J
c) Approximately how many people use the facility when it is occupied? p?
d) When was the wastewater system installed? /9 7 6
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: I i�i t- /�C, -
f
s-Ala
(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.
4 �,, „ , . ,; NC DENR/DWQ/NPDES
h `'" ' 1617 Mail Service Center
Raleigh, NC 27699-1617
Page 2 of 2

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H.Sullins Dee Freeman
Governor Director Secretary
March 24, 2009
CERTIFIED MAIL ITEM 7003 1680 0001 0742 8793 -RETURN RECEIPT REQUESTED
Mr. Eric Fields
1009 Augusta Court
Kernersville, N.C. 27284
Subject: Notice of Violation
Failure to Submit Renewal Application
General Permit NCG550000
Certificate of Coverage (CoC)NCG550080
Forsyth County
Dear Mr. Fields:
General Permit NCG550000 expired on July 31, 2007. North Carolina Administrative Code (15A
NCAC 2H.0105 (e))requires that an application for permit renewal be filed at least 180 days prior to
expiration of the current permit. To satisfy this requirement,your renewal package should have been sent
to the Division postmarked no later than February 1,2007.
The Division did not receive a renewal request for the subject CoC,which covers your residence.
This is a violation of your permit at Part II. B. 9,which states"If the permittee wishes to continue an activity
regulated by this permit after the expiration date of this permit,the permittee must apply for and obtain a
new permit."
In order to prevent an assessment of civil penalties you must submit a completed renewal application
(enclosed)no later than April 10, 2009.
If all wastewater discharge from your facility has ceased and you wish to rescind this permit, or if
you have any other questions,contact Charles Weaver of my staff. Mr. Weaver's telephone number,fax
number and e-mail address are listed at the bottom of this page.
Sincerely,
c:4141 etz600t
gi.4
Coleen H. Sullins
cc: Central Files /
Winston-Salem Regional Office/Rose Pruitt
NP-pE File i
1617 Mail Service Center,Raleigh, North Carolina 27699-1617 One •
512 North Salisbury Street,Raleigh,North Carolina 27604 NorthCarohna
Phone: [phone] /FAX [phone]/[e-mail] Natuyallff
Internet:www.ncwaterquality.org L II7'
An Equal Opportunity/Affirmative Action Employer—50%Recycled/10%Post Consumer Paper

SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. j //-' 0 Agent
• Print your name and address on the reverse X / ❑Addressee
so that we can return the card to you. Pre R: eived by(Print-.Name) C. Date of Delivery
• Attach this card to the back of the mailpiece, j v� �, �(� f_ �c
or on the front if space permits.
d. Is delivery address different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑ No
ERIC FIELDS
1009 AUGUSTA COURT 3. Service Type
KERNERSVILLE NC 27284 ❑Certified Mail ❑Express Mail
❑Registered 0 Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) 0 Yes
2. Article Number
7003 1680 0001 0742 8793
(transfer from service label)
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540

UNITED STATESIP rAI&8 R1e :C.V 4 IIy:, Y,. . M. -''''.-,.—,4'`i ... I
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• Sender: Please print your rimeavED
Charles H. WeaverAPR 1 3
q.NC DENR / � &,
DWQ / NPDES Uni 9.
1617 Mail Service Center
Raleigh, Is EN %-VffltR QUALITY
POO:NT SOURCE BRANCH
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