NCG550127_Permit (Issuance)_20070731

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.NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Michael F. Easley, Governor William G. Ross,Jr.,Secretary
Coleen H.Sullins, Director
July 31, 2007
Zachary T. Harris
2162 Upper Lk Rd
Thomasville,NC 27360
Subject: Renewal of coverage/General Permit NCG550000
2162 Upper Lake Road
Certificate of Coverage NCG550127
Davidson County
Dear Permittee:
In accordance with your renewal application [received on February 1, 2007],the Division is renewing
Certificate of Coverage(CoC)NCG550127 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 May 9, 1994 [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 Toya
Fields [919 733-5083, extension 551 or [e-mail]] or Susan Wilson [919 733-5083,extension 510
or [e-mail]].
Sincerely,
•
for Coleen H. Sullins
cc: Central Files
Winston-Salem Regional Office/Surface Water Protection
03106401'
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 Naturally
An 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 NCG550127
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,
Zachary T. Harris
is hereby authorized to discharge domestic wastewater [450 GPD] from a facility located at
2162 Upper Lake Road
Thomasville
Davidson County
to receiving waters designated as an unnamed tributary to Hamby Creek in subbasin 03-07-07 of
the Yadkin 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 August 1, 2007.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day July 31, 2007.
for Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission

North Carolina Department of Environment and Natural Resources
Division of Water Quality
RENEWAL FORM FOR EXISTING PERMITTED FACILITIES
NPDES renewal application for continued coverage under General Permit NCG550000:
Certificate of Coverage NCG550127
(Please verify the information in items 1 &2 as correct, or note any corrections that should be made.)
(Please print or type all other answers)
1) Mailing address* of property owner: t
i / FEB 0 1 2007
Owner Name Zachary Harris/ gg
Street Address ` :'" f"'- Z" '® 2,(0,2 cam- LA-�` 'Rd • k
Address Thomasville,NC 27360
Telephone . (Home) 3'(o 3 - 3536 (Mobile) 3g6 4142-/7(a2-
(e-mail address)
Address to which all permit correspondence will be mailed
2) Location of facility producing discharge*:
Facility ID ghl4ennis-Residence Bari'%$ , 2acl'tarr j
Address: 2162 Upper Lake Rd, 4
Thomasville,NC 27360 (Davidson County)
Telephone (Home) _ (Mobile)
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):
Primary residence
❑ Vacation/second home
❑ Undeveloped property
❑ Other [describe]:
4) Please check the components that comprise the wastewater treatment system:
f Septic tank El Dosing tank [ 1 Primary sand filter ❑ Secondary sand filter
❑ Recirculating sand filter(s) [ Chlorination ❑ Dechlorination
❑ Other form of disinfection: ❑ Post Aeration(describe)
Page 1 of 2

NCG550000 renewal form
5) Other Information: __ II /
a) When was the septic tank last pumped out? 1 04 5U ,'r1, P A/ .AOme 00in R/o(
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? 4&r &Wild
c) Approximately how many people use the facility when it is occupied?
d) When was the wastewater system installed? A/A
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: 2aGha. 77 )Iv-r-y3
00/0
(Signatur of App icant) (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

Michael F.Easley,Governor
5 �
_ �,, William G.Ross Jr.,Secretary
ti- - - North Carolina Department of Environment and Natural Resources
C' ti F _L3 e Z ' Alan W.Klimek,P.E.Director
Division of Water Quality
SURFACE WATER PROTECTION SECTION
•
PERMIT NAME/OWNERSHIP CHANGE FORM
I. Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
N C y ss O , .2- 7 N C G
II. Permit status prior to status change.
a. Permit issued to(company name):
b. Person legally responsible for permit: 2'E'.—/S /t z/�/vf•l
First / MI / Last
Title
s.4,/a7 /7�,�T�� �0
Permit Holder Mailing Address
/7 o- 14sv/LLB ,mac 27.G 0
City State Zip
( ) ( )
Phone Fax
c. Facility name(discharge):
d.Facility address: 2 / G 2 U F'f 2 /./f/�� i.P
Address
7/i0 /�7,frq-CG% c /G ,2 `77 C_
City State Zip
• e. Facility contact person: ( )
First / MI / Last Phone
III. Please provide the following for the requested change(revised permit).
a. Request for change is a result of: a Change in ownership of the facility
❑ Name change of the facility or owner
If other please explain:
b.Permit issued to(company name): 7aLko.4-y 7/ .- 3 7
c. Person legally responsible for permit: 1�
First / MI / Last
r�' Title
(02- [��/Gig gj
Permit Holder Mailing Address
•
AoM+esa";Ile /VL - Z:73Coc
• City State Zip
(�31. ) 3/3—35 3&
Phone E-mail Address
d. Facility name(discharge):
e. Facility address: Z/(oZ 4/wee-ice ,zd
Address
7#►+r s c,47le 2-7 3 !a
City State Zip
f. Facility contact person:
First / MI / Last
( )
Phone E-mail Address
Revised 7/2005
1

PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
IV. 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
V. Will the permitted facility continue to conduct the same industrial activities conducted prior to
this ownership or name change?
❑ Yes
❑ No(please explain)
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 relevant pages of a contract deed, or a bill
of sale) is required for an ownership change request. Articles of incorporation are not sufficient for
an ownership change.
' The certifications below must be completed and signed by both the permit holder prior to the change, and the new
applicant in the case of an ownership change request. For a name change request, the signed Applicant's Certification
is sufficient.
PERMITTEE CERTIFICATION(Permit holder prior to ownership change):
I, _£'i.-pis 1��,./'(4- , 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.
,e".��" /- 6, 0 7
Signature Date
APPLICANT CERTIFICATION:
I, Zuc�-•-•-y 7-- +r-5: , attest that this application for a name/ownership
cha as 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.
"--/7_, 777/74-- /40 47
Signature Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh,North Carolina 27699-1617
Revised 7/2005

DAVIDSON COUNTY NC 07/28/2006
3S' $190.00 DAVIDSON COUNTY NC tIII
STnTE0f H Book 1717
paCLINA + , Excise S Tax 1236-1237
�a Pages
FILED 2 PAGE(S)
07/28/2006 2:56 PM
MARK C. MYERS
Register Of Deeds
NORTH CAROLINA
GENERAL WARRANTY DEED
Excise Tax: $ 190.00 Recording Time, Book and Page
Tax Map No. Parcel Identifier No. 16-340-F-000-0015
Mail after recording to: Grantee: 2162 Upper Lake Road,Thomasville,NC 27360
This instrument was prepared by:Mark L.McGuire,Attorney at Law,Thomasville,NC 27360
THIS DEED made this ' 24 day of July , 2006 by and between
GRANTOR
Danis K. Val, uiiaed
GRANTEE
Zachary Todd Harris and wife,Ashley Hulin Harris
2162 Upper Lake Road
Thomasville,NC 27360
The designation Grantor and Grantee as used herein shall include said parties,their heirs, successors,and assigns, and shall
include 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 and more particularly described as follows:
BEING: Lot No. 15 of CHARTER OAKS,according to the plat thereof,which is duly recorded in Plat Book 16,Page 51,in
the Office of the Register of Deeds for Davidson County,North Carolina.
0021007

f •
a portion of the property hereinabove described was acquired by Grantor by instrument recorded in Book 1267 , Page
Davidson County Registry.
A map showing the above described property is recorded in Plat Book 16 , Page 51 ,and referenced within this instrument.
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances thereto belonging to the
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 in fee simple,that title is marketable and free and clear of all encumbrances, and that Grantor will warrant and defend
the title against the lawful claims of all persons whomsoever except for the exceptions hereinafter stated.
Title to the property hereinabove described is subject to the following exceptions:
Power,telephone and utility easements of record or those visible upon the ground,if any.
terns i wj iJ in Hick 505, I 656
IN WITNESS WHEREOF,the Grantor has hereunto set his hand and seal,or if corporate, has caused this
instrument to be signed in its corporate name by its duly authorized officer(s),the day and year first above
written.
. �/J� ��✓ (SEAL)
(ENTITY NAME) nnis K Vaughan
By: (SEAL)
By: (SEAL)
(SEAL)
NORTH CAROLINA Davidson COUNTY „
a P uv. ca
l Arnicia Bryant Whitley , a Notary Public; stbe ✓,ounty and State aforesaid, certify Danis K. vaxim,
Grantor(s), personally appeared before me this day and acRCiibwledged the execution Of the foregoing instrument. witness
my hand and official stamp or seal, this the 27 day of Ju y _ , 2006
My Commission Expires: 1-19-2009
iVot Ty Public
Arnicia Bryant Whit1
NORTH CAROLINA COUNTY
I, , a Notary Public of the County and State aforesaid, certify that
personally appeared before me this day and acknowledged that he/she is the
of , a North Carolina corporation/limited liability company/general
partnership/limited partnership(mark through the inapplicable), and that by authority duly given and as the act of such entity,
he/she signed the foregoing instrument in its name on its behalf as its act and deed. Witness my hand and official stamp
or seal, this the day of
My Commission Expires:
Notary Public