NCG550099_Permit (Issuance)_20101112

gris,
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue,Governor Coleen H. Sullins, Director Dee Freeman, Secretary
November 12, 2010
Sande L. Erwin & Patricia L. Erwin
3060 Cedar Creek Drive
Kernersville,NC 27284
Subject: Renewal of coverage/General Permit NCG550000
3060 Cedar Creek Drive
Certificate of Coverage NCG550099
Forsyth County
Dear Permittee:
In accordance with your renewal application [received on November 8, 2010], the Division is
renewing Certificate of Coverage (CoC)NCG550099 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,
for Coleen H. Sullins
cc: Central Files
Winston-Salem Regional Office/Surface Water Protection
NPDES file
1617 Mail Service Center,Raleigh,North Carolina 27699-1617 One
512 North Salisbury Street,Raleigh, North Carolina 27604 NorthCarolina
Phone: [phone]/FAX [phone]/Internet:www.ncwaterquality.org 7VaturallAn Equal Opportunity/Affirmative Action Employer—50%Recycled/10%Post Consumer Paper

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NCG550000
CERTIFICATE OF COVERAGE NCG550099
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,
Sande L. Erwin & Patricia L. Erwin
is hereby authorized to discharge domestic wastewater [450 GPD] from a facility located at
3060 Cedar Creek 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, III and IV hereof.
This certificate of coverage shall become effective November 12, 2010.
This Certificate of Coverage shall expire on July 31, 2012.
Signed this day November 12, 2010
f r Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission
1

A • Division of Water Quality/Water Quality Section
National Pollutant Discharge Elimination System
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT ANC NATURAL RESOURCE, NCG550000
RENEWAL FORM FOR EXISTING PERMITTED FACILITIES
NPDES renewal application for continued coverage under General Permit NCG550000:
Certificate of Coverage NCG55t1O(f
(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 SANDE L. & PATRICIA L. ERVIN
Street Address 3060 CEDAR CREEK DRIVE
City KERNERSVILLE, NC 27284
Telephone (Home) 336 996-5392 (Mobile) 336 407-3725
(e-mail address) aervin50@hotmail .com
*Address to which all permit correspondence will be mailed
2) Location of facility producing discharge*:
Street Address 3060 CEDAR CREEK DRIVE
City: KERNERSVILLE, NC
County FORSYTH
Telephone (Home)_ 336-996-5392 (Mobile) 336 407-3725
* 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):
XXX Primary residence
❑ Vacation/second home
❑ Undeveloped property
❑ Other [describe]:
NOV - 8 2010
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 0 Dosing tank 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? 06-05-2007
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? 1
d) When was the wastewater system installed? 1979
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: PATRICIA L. E R V I N
(4. -0-?,4- �-V D11-03-10
(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
Page 2 of 2

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T----':' GERMANTON, NC 27019
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•
t.
•
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
October 25th, 2010
Ann Ervin, Owner
3060 Cedar Creek Drive
Kernersville, NC 27284
Subject: Compliance Evaluation
NPDES General Wastewater Discharge Permit — NC550000
Certificate of Coverage NCG550099
Single Family Residence 3060 Cedar Creek Drive, Kernersville, NC 27284
Forsyth County
Dear Mrs. Ervin:
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 3060 Cedar Creek Drive, in Kernersville,
Forsyth County, North Carolina, on October 20th, 2010. Your assistance and cooperation was
greatly appreciated. Inspection findings are summarized below and an inspection report is attached
for your records.
There were no chlorine tablets in the chlorinator at the time of the inspection and there was no
discharge. The creek appeared to be healthy and unaffected by the discharge. You told Mr. Boone
that your husband used to take care of the system and that you are unfamiliar with it. Mr. Boone
advised you where you could acquire chlorine tablets, how to feed them and maintain the chlorinator.
You told Mr. Boone that the tank had been pumped within the last couple of years but did not
immediately have access to the record. Mr. Boone advised you to start keeping all records as
required by the permit.
Mr. Boone says that he sent you all necessary info via email but it is all attached to this letter
as well. Please fill out the permit renewal 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 as required.
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 Naturally
An Equal Opportunity 1 Affirmative Action Employer � j`

•
Ann Ervin
ti
3060 Cedar Creek Drive, NCG550099
Compliance Evaluation Inspection
October 25,2010
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,
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
$, Pe.v'v 1;-t Re.p,c Poo.,
cc: WSRO — SWP w/ atch
Central Files w/ atch
NPDES West Unit, Charles Weaver

United States Environmental Protection Agency Form Approved.
EPA 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 15I 31 NCG550099 111 121 l0/10/20 117 18I CI 19I G I 20U
Remarks t— -J
21IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII11166
Inspection Work Days Facility Self-Monitoring Evaluation Rating B1 QA Reserved
671 169 701 II 711 I 721111 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)
04:30 PM 10/10/20 02/08/01
3060 Cedar Creek Drive 1
3060 Cedar Creek Dr Exit Time/Date Permit Expiration Date
Kernersville NC 27284 05:30 PM 10/10/20 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
Sande L Ervin,3060 Cedar Creek Dr Kernersville NC 27284//919-996-5392
0
Section C: Areas Evaluated During Inspection(Check only those areas evaluated)
II 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/
Signature of Management Q A eviiewer Agency/Office/Phone and Fax Numbers Date
W, �O1----- //'fie-( %e
EPA Form 3560-3(Rev 9-94)Previous editions are obsolete.
Page# 1

NPDES yr/mo/day Inspection Type (cont.) 1
3, NCG550099 I11 12I 10/10/20 I17 18kI
Section D: Summary of Finding/Comments(Attach additional sheets of narrative and checklists as necessary)
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 3060 Cedar Creek Drive, in Kernersville, Forsyth County, North
Carolina, on October 20th, 2010. Your assistance and cooperation was greatly appreciated. Inspection
findings are summarized below and an inspection report is attached for your records.
There were no chlorine tablets in the chlorinator at the time of the inspection and there was no discharge.
The creek appeared to be healthy and unaffected by the discharge. You told Mr. Boone that your husband
used to take care of the system and that you are unfamiliar with it. Mr. Boone advised you where you could
acquire chlorine tablets, how to feed them and maintain the chlorinator. You told Mr. Boone that the tank
had been pumped within the last couple of years but did not immediately have access to the record. Mr.
Boone advised you to start keeping all records as required by the permit.
Mr. Boone says that he sent you all necessary info via email but it is all attached to this letter as well.
Please fill out the permit renewal 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 as required.
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.
Page# 2

Permit: NCG550099 Owner-Facility: 3060 Cedar Creek Drive
Inspection Date: 10/20/2010 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? norm
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 U n
Is the inspector granted access to all areas for inspection? n n n n
Comment: Please refer to the attached inspection summary letter.
Page# 3