NCG550108_Permit (Issuance)_20161128

PAT MCCRORY
•
Governor
DONALD R. VAN DER VAART
Sect eta°
Water Resources S. JAY ZIMMERMAN
ENVIRONMENTAL QUALITY
Director
November 28, 2016
Ms. Jennifer I. Lewis
8095 Deverow Court
Lewisville, NC 27023
Subject: General Permit NCG550000
8095 Deverow Court
Certificate of Coverage NCG550108
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 NCG550108.
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
brianna.young@ncde nr.gov].
S' erely,
/(-
ZL
-
/6.
for S. Jay Zimmerm .G.
Director, Division of Water Resources
cc: Winston-Salem Regional Office
NPDES File
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
https://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 NCG550108
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,
Jennifer I. Lewis
is hereby authorized to discharge <1000 gallons per day of domestic wastewater from a
facility located at
8095 Deverow Court
Lewisville
Forsyth County
to receiving waters designated as an unnamed tributary to Mill Creek, a class WS-IV stream in
subbasin 03-07-02 of the Yadkin Pee-Dee 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 takes effect November 28, 2016.
This Certificate of Coverage shall remain valid for the duration of the General Permit.
Signed this day November 28, 2016.
for Jay Zimmerman .
Director, Division o ater Resources
By Authority of the Environmental Management Commission

PAT MCCRORY
•
J j.a
DONALD R. VAN DER VAART
Secretary
Water Resources S. JAY ZIMWV N
ENVIRONMENTAL QUALITY INgiNCCEQICWR
NPDES Certificate of Coverage (CoC) V Y c + ,0
OWNERSHIP CHANGE FORM ter QUajity
I. Please enter the CoC number for which the change is requested. Permitting Section
Certificate of Coverage
N C G 5 5 01. C> $
II. Please provide the following for the requeste change(revised permit).
a. Request for change is a result of: 2 Change in ownership of the residence/property
❑ Name change of the facility or owner
If other please explain:
b. Permit will be issued to(company
name, if applicable):
c. Person legally responsible for permit: _ je.nrc.c.✓ s
First MI Last
���r/. Title
(
,C •� OCvCX OIL c O V-
Permit Holder Mailing Address
2162.1
City State Zip
(92.45 ) 301-to3t\ ��,�.\.
Phone E-mail Address
d. Facility name(discharge):
e. Facility address: (80915 1( e CID,,•k
Address
L,cw.sv Ake_ tJ L 216 2 3
City State Zip
f. Facility contact person: `cn�: "� �,w�s
First MI Last
(°1r° ) go-t 3I.1 1xw,;It21el.vi wry.
Phone E-mall Address
III. Permit contact information (if different from the person legally responsible for the permit)
Permit contact:
First MI Last
Title
Mailing Address
City State Zip
( )
Phone E-mail Address
N Will this permitted facility continue to discharge the same volume and type of wastewater as
pr;or to this ownership or name change?
Yes
❑ No (please explain)
Revised 9/2016

NCG550000 OWNERSHIP CHANGE FORM
Page 2 of 2
VI Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both name change and/or ownership change
requests.
❑ Legal documentation of the transfer of ownership(such as a property deed,relevant pages of a
contract,or a bill of sale)is required for an ownership change request.
The certifications below must be completed and signed by the new applicant in the case of an ownership
change request.
APPLICANT CERTIFICATION
I, ,attest that this application for a name/ownership change has been reviewed and is accurate and
complete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting information is not included,this application package will be
returned as incomplete.
iU /204
j%� Si ture Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
NC DEQ/DWR/NPDES
1617 Mail Service Center
Raleigh,North Carolina 27699-1617
Revised 9/2016

NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: $
Parcel Identifier No.: 5876-81-0450.00(Block 4612B,Lot 020C)
Return after recording to: Kangur&Porter, LLP (Box 76)
Mail tax bills to Grantee: 8095 Deverow Ct., Lewisville,NC 27023
This instrument was prepared by:T.Thomas Kangur,Jr.
Brief description for the Index: Portion of Lot 20, Shallowford Forest,Section 5
THIS DEED made this 17th day of June,2015,by and between,
GRANTOR GRANTEE
AUGUSTUS C. GONDRING and wife, JENNIFER IRENE LEWIS, unmarried
MAJORA K. GONDRING Mailing Address:
Mailing Address: 8095 Deverow Ct., Lewisville,NC 27023
The designation Grantor and Grantee as used herein shall include said parties,their heirs,successors,and assigns,and shall includf
singular, plural,masculine, feminine or neuter as required by context.
WITNESSETH,that the Grantor, for a valuable consideration paid by the Grantee,the receipt of which is hereby acknowledged,
has and by these presents does grant,bargain,sell and convey unto the Grantee in fee simple,all that certain lot or parcel of land
situated in the Vienna Township,Forsyth County,North Carolina and more particularly described as follows:
SEE EXHIBIT A ATTACHED HERETO AND INCORPORATED HEREIN BY REFERENCE
Property Address: 8095 Deverow Ct., Lewisville,NC 27023
As attested by their signature(s) hereto, the Grantor(s) certify that the property conveyed hereby does IX I, does not
include the primary residence of the Grantor(s).
The property hereinabove described was acquired by Grantor by instruments recorded in Book 1548, Page 724, Forsyth Count)
Registry.
A map showing the above described property is recorded in Plat Book 26,Page 175.

•
l
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances thereto belonging to th,
Grantee in fee simple.
And the Grantor covenants with the Grantee,that Grantor is seized of the premises in fee simple,has the right to convey the same it
fee simple,that title is marketable and free and clear of all encumbrances,and that Grantor will warrant and defend the title against
lawful claims of all persons whomsoever,other than the following exceptions: Subject to all easements,rights-of-way and
restrictions of record,if any,and ad valorem taxes for the current year.
IN WITNESS WHEREOF,the Grantor has duly executed the foregoing as of the day and year first above written.
4V`(A•2.1"". ( _�_ b� Z` :A .L4 AIF (SEAL)
AugdStus C.Gondring, by Film ugustus Gondrig,AIF
M,Ni .q„ b A l F (SEAL)
Majora K.Gondring,by K'im Augustus Gondrint,AIF
State of North Carolina ,County of St.
ck. r I( 1, (( m ,a Notary Public of 1 j LJ T i County,North Carotin;
do hereby certify that Kim Augustus Gondring,Attorney-in-Fact for Augustus .Gondring`and wife, Majora K.Gondring,
personally appeared before me this day,and being duly sworn,says that,he/she executed the foregoing and annexed instrument for
and on behalf of Augustus C. Gondring and wife,Majora K.Gondring_and that his/her authority to execute and acknowledge said
instrument is contained in an instrument duly executed,acknowledged and recorded in the Office of the Register of Deeds of
Forsyth County,North Carolina, in Book 3014 Page 4258 and Book 3014 Page 4269,and that this
instrument was executed under and by virtue of the authority given by said instrument granting him/her power of attorney;and that
said Kim Augustus Gondring acknowledged the due execution of the foregoing and annexed instrument for the purpose therein
expressed for and in behalf of said Augustus C. Gondring and wife,Majora K.Gondring.
Date: 1f' 1
j_ 10 5 PATRICIA F. KIRKMAN
b f Notary Public-North Carolina
Forsyth County
�f �U 01
Notary Public My Commission Expires:
ti C \ to vita i]
printed or typed name of notary public

PAT MCCRORY
Governor
DONALD R.VAN DER VAART
Secretary
Water Resources S.JAY ZIMMERMAN
ENVIRONMENTAL QUALITY
Director
October 10,2016
Ms. Jennifer I. Lewis
8095 Deverow Court
Lewisville,NC 27023
Subject: Wastewater Disposal at
8095 Deverow Court, Lewisville
Certificate of Coverage(CoC)NCG550108
Forsyth County
Dear Ms. Lewis:
Forsyth County tax records list Ms.Jennifer I.Lewis as the current owner of the subject property. We are
contacting you to determine the status of a wastewater disposal system on your property that was covered by General
Permit NCG550000 under CoC NCG550108. The last CoC was issued to Augustus C. Gondring on 7/15/2015.The
Division needs information from you to determine if coverage under NCG550000 is still necessary. Please respond by
November 28,2016 with one the following:
> If you are the current owner of this property and it still has a wastewater system like the ones described in the
enclosed Technical Bulletin,you must submit a change in ownership form. Please complete the enclosed form
and submit it to Charles Weaver at the address on the form. In addition,a$60 in overdue annual fees is
required to maintain this permit. Please send payment for the enclosed invoice(s):
2015PR010852.
(Payment instructions are provided on the invoice.)
> If you know that your property no longer discharges wastewater and the treatment system has been replaced
with a different treatment system or connected to a city sewer,please contact me at the address or phone
number listed below to request rescission of the CoC.
> If you are not sure what type of system your property has, contact George Smith in the NC DEQ Winston-
Salem Regional Office at 336-776-9800. This contact [or other staff members] can help you determine if you
should maintain your CoC.
If you have questions concerning this matter,please do not hesitate to contact me at 919-807-6479 or
[e-mail].
Sincerely,
Meredith Wojcik
Division of Water Resources,DEQ
cc: Winston-Salem Regional Office,DWR WQRO
NPDES General Permit Files
Teresa Revis,DWR Budget Office
State of North Carolina I Environmental Quality I Water Resources
1611 Mail service Center I Raleigh,North Carolina 27699-1611
919 707 9000