NCG550181_Permit (Issuance)_20151130

PAT MCCRORY
DONALD R. VAN DER VAART
w
Water Resources S. JAY ZIMMERMAN
ENVIRONMENTAL QUALITY
November 30, 2015
Charles B. Tillotson
2117 Bethlehem Church Road
Reidsville, NC 27320
Subject: General Permit NCG550000
2117 Bethlehem Church Road
Certificate of Coverage NCG550181
Rockingham County
Dear Permittee:
The Division received your request to transfer ownership of the subject Certificate of Coverage (CoC)
on November 19, 2014. Due to an error by a temporary employee, the request was misfiled and not found
until today. The Division apologizes for the error, and for the delay in responding to your request. We
hereby issue you an updated version of NCG550181 under General Permit NCG550000. It 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 Charles Weaver of the NPDES staff[919 807-6391 or
[e-mail]].
diperely,
G
'n.
for S.Jay Zimmerman, Dire..
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
httpJ/portal.ncdenr.org/web/wq

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER RESOURCES
GENERAL PERMIT NCG550000
CERTIFICATE OF COVERAGE NCG550181
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,
Charles B. Tillotson
is hereby authorized to discharge <1000 gallons per day of domestic wastewater from a
facility located at
2117 Bethlehem Church Road
Reidsville
Rockingham County
to receiving waters designated as an unnamed tributary to Town Creek, a class C stream in
subbasin 03-02-03 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 takes effect November 30, 2015.
This Certificate of Coverage shall remain valid for the duration of the General Permit.
Signed this day November 30, 2015
foS` ay Zimmerman, Director �>
Ullivision of Water Resources
By Authority of the Environmental Management Commission

Cirg
—^ Division of Water Quality/Water Quality Section
NCDENRNational Pollutant Discharge Elimination System
NORTH CAROLINA DEP THEM OF
ENNRONMENT AND NATURAL RESOURCES NCG550000
RENEWAL FORM FOR EXISTING PERMITTED FACILITIES
NPDES renewal application for continued coverage under General Permit NCG550000:
Certificate of Coverage NCG5500)\
f )
(Please print or type)
1) Mailing address* of property owner: ./
Owner Name tie 1 i=S . ! 1L aSa4
Street Address
a /7 1fd/(4,4 4
City f, Ac l"��� G o2 '7 3 20
Telephone (Home) 3 34 (Mobile) 3tJG 'Tr"- 0 6o4a
(e-mail address) l/ o�'S a s�1 7 Off q /ri 4, / - e O h.,
* Address to which all permit correspondence will be mailed
2) Location of facility producing discharge*:
Street Address x / / d £h f C9)/�y IA49
City: F.cP ✓///t C o� ['1 3 2 v ,
County yC D G"'/Gj/Zw r►'r
Telephone (Home) - b 33"1 a(1-4, (Mobile) 3(1 G 4 7- `�C 1-3
*If the facility is not yet constructed, give the street address or lot number where the structure will be
built.
3) Description of Discharge: RECEIVED/DENR/DWR
a) Type of facility producing waste (please check one):
Lr Primary residence NOV 1 9 2014
0 Vacation/second home P Water Quality
mng Section
❑ Undeveloped property
0 Other [describe]:
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•
NCG550000 renewal form •
4) Please check the components that compriseri the wastewater treatment system:
L9'Septic tank ❑ Dosing tank P(Primary sand filter ❑ Secondary sand filter
❑ Recirculating sand filter(s) Chlorination 0 Dechlorination
0 Other form of disinfection: 0 Post Aeration(describe)
5) Other Information:
a) When was the septic tank last pumped out? elf Aliiiv,k©
NOTE: the septic tank must be pumped out at least once every 3-5 years
�Zs
b) Is the facility [home] occupied year-round, or only seasonally? &)%r1- 6)40 1
c) Approximately how many people use the facility when it is occupied?
d) When was the wastewater system installed? \ \(\\
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: , L/ ` / 0keiV
yva. m
�`- 1/, 1
(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
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