NCG550200_Permit (Issuance)_20150123

Aft,
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory,Governor Donald R.van der Vaart, Secretary
January 23, 2015
Nicole Goad
166 Forestdale Dr
Reidsville, NC 27320
Subject: General Permit NCG550000
166 Forestdale Dr
Certificate of Coverage NCG550200
Rockingham County
Dear Permittee:
The Division received your request to update the owner's name for the subject Certificate of
Coverage (CoC) on November 25, 2014. Therefore, the Division hereby reissues NCG550200 under General
Permit 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 toyou,you have the right to request an individua
l g q 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]].
Since'ely,
/1/,/f2-1,X
Jay Zimmerman, Acting Director
Division of Water Resources
cc: Winston-Salem Regional Office
NPDES file
1617 Mail Service Center,Raleigh,North Carolina 27699-1617 512 North Salisbury Street,Raleigh,North Carolina 27604
Phone: [phone]/FAX [phone]/Internet:www.ncwaterquality.org
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STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER RESOURCES
GENERAL PERMIT NCG550000
CERTIFICATE OF COVERAGE NCG550200
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, the
Nicole Goad
is hereby authorized to discharge <1000 gallons per day of domestic wastewater from a
facilitylocated
ated at
166 Forestdale Dr
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 January 23, 2015.
This Certificate of Coverage shall remain valid for the duration of the General Permit.
Signed this day January 23, 2015
/2),,Z
for J immerman, Acting Director
ivision of Water Resources
By Authority of the Environmental Management Commission

November 17, 2014
Division of Water Resources/Water Quality Permitting Section RECEIVED
1617 Mail Service Center GVG
Raleigh, NC 27699 NOV 2 5 Z°.4
L FILES
CENT
SECTION
Reference:#NCG550200
To Whom It May Concern:
I received a letter in the mail (provided a copy on the following page). It stated that I needed to fill out a
change of ownership form and mail it in. I have done so and attached that to this letter. It stated in the
letter that an inspector came out but could not get the cap off of the chlorinator tubes to check for
chlorine tablets. It also stated that the septic tank needs to be pumped out every five years. I purchased
the house in August of 2013. I was made aware of the need for chlorine tablets when purchasing the
house so I have put those in the tubes. I also had the septic tank pumped out shortly after I moved in. I
did not save the receipt so I'm not sure if you need to be provided proof of any of this or how I could
even go about doing that? I have also paid the permit fee for 2013 and paid it again this year. I didn't
realize that you had not been made aware of the change of ownership since the request for payment
came in MY name not the previous owner. It wasn't until this year that I noticed the permit was still
listed in the previous owners name even though it was mail to me. That's why I mailed a letter stating
that I was the new owner of the property along with my last payment and then I received the letter I
was referring to above. I want to make sure that my payment for the permits is in my name and I will
not have to pay again. Also if you need to be provided proof of the chlorine tablets or the septic tank
being pumped out I will need to know ahead of time. Please contact me at the information below.The
best method would be email as I work Monday- Friday.
Sincerely,
Nicole Goad
166 Forestdale Drive
Reidsville, NC 27320
[e-mail]
[phone]

ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory John E. Skvarla, III
Governor WATER QUALITY PERMITTING SECTION Secretary
PERMIT NAME/OWNERSHIP CHANGE REQUEST
This form is for ownership changes or name changes of NPDES wastewater permits.
• "Permittee" references the existing permit holder
• "Applicant" references the entity applying for the ownership/name change.
L NPDES Permit No. (for which the change is requested): N C 0 0
or
Certificate of Coverage#: N C G 5
II. Existing Permittee Information:
a. Permit issued to(company name):
b. Person legally responsible for permit: W`t
First MI Last
Title
kko
Permit Holder Mailing Address
�SU\Mr, \\ Y)3 ao
City State Zip
( ) ( )
Phone Fax
c. Facility name:
d. Facility's physical address:
Address
City State Zip
e. Facility contact person: ( )
First / MI / Last Phone
IIL Applicant Information:
a. Request for change is a result of: ❑ Change in ownership of the facility
dame change of the facility or owner
If other please explain:
b. Permit issued to(company name):
c. Person legally responsible for permit: Kr) t�l 2 "r— Go A[
First MI Last
t\ el ) kAorY Q�-r`cQr
Title
lD(o -For d a 1 e. D r;tee_
Permit Holder Mailing Address
svc�l� aF73a0
City Stat Zip
M/1 a 51-'75aa r�a t r600aCe
Phone E-mail Address
Page 1 of 2 Revised 7/01/2014

d. Facility name:
e. Facility's physical address: I b ' Oc CSC
Address
City State Zip
f. Facility contact person: C\-\jp-A_.r-,
First MI Last
Title
)
Phone E-mail Address
IV. Will the permitted facility continue to conduct the same commercial/industrial activities conducted prior to
tbilpwnership or name change?
Yes
ex; No(please explain) \S l S G VNOC(112_, Cf es id e'14,c; ti (-MrnerCi at at 41 J i 1,.,
If applicable,the applicant shall submit a major permit modification request to DWR A major modification shall be
defined as one that increases the volume,increases the pollutant load, results in a significant relocation of the
discharge point,or results in a change in the characteristics of the waste generated.
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS ARE
INCOMPLETE OR MISSING:
1. This completed application is required for both name change and/or ownership change requests.
2. 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
Applicable regulations: 40 CFR 122.41,40 CFR 122.61 and 15A NCAC 02H .0114
The certifications below must be completed and signed by both the permit holder prior to the change(Permittee),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, ,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.
Signature Date
APPLICANT CERTIFICATION
I, vTro,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.
I I/1 1 /! Li
Signature Date
**************************
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh,North Carolina 27699-1617
NPDES PERMIT NAME/OWNERSHIP CHANGE REQUEST
Page 2 of 2 Revised 7/01/2014

. BOOK 1462 PAGE 175 (4) `~J
516615
Filed
Rockingham County, NC
Rebecca B. Cipriani, Register of Deeds
08/23/2013 10:28:24 AM
Fee Amt: $26.00 NC Excise Tax:$180.00
CHERYL D. CHRISMON
NORTH CAROLINA GENERAL WARRANTY DEED
/ Revenue Stamps: $180.00
v Mail after recording to GRANTEE-
v This instrument was prepared by Joseph G. Maddrey
Brief description for the Index
THIS DEED made this ao2Pobay of /4 j UST , 2013, by and between
GRANTOR GRANTEE
William N. Parks, divorced Nicole T. Goad
and
Sandra H. Parks, divorced
Address: 251 Glass Road Address: 166 Forestdale Drive
Reidsville, NC 27320 Reidsville, NC 27320
Enter in appropriate block for each party: name,address,and if appropriate,character of entity,e.q. corporation or partnership
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 situated in Rockingham County, North
Carolina and more particularly described as follows:
See Exhibit A Attached.

I
:.rty herein above described was acquired by Grantor by instrument recorded in
map showing the above described property is recorded in Plat Book , page
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:
Taxes for the current year, rights-of-way of public highways and roads and public
utilities, easements and restrictions of public record.
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 officers and its seal to
be hereunto affixed by authority of its Board of Directors, the day and year first above written.
(USE BLACK INK ONLY)
r
(SEAL)
William N. Parks
SEAL-STAMP NORTH CAROLINA, Qj n ry- County.
0�`���,,'KAR,,�,, I, Gen 6.. I1 a Notary Public of the County and State aforesaid,
' d' certi that William N. Parks, personally appeared before me this day and
oa N O� �- acknowledged the execution of the foregoing instru nt. Witness my hand and
9-53 r_official stamp or seal, thisalday of , 2013.
_ aiS ,
=-5, 0,
- /C My commission expires: 1:),7-ay �, <
„%-,0L,N TY,N�;.•%� Not ry Public
V

(SEAL)
Sandra H. Parks
SEAL-STAMP NORTH CAROLINA, County.
���,•�`REN S,,,,, I, ( , a Notary Public of the County and State aforesaid,
' T<.' ; certi that Sandra H. Parks, personally appeared before me this day and
irs \A O TA ,acknowledged the executi. o the forego g instrument. Witness my hand and
'- official stamp or seal, thi•► • day of us , 2013.
8 L l My commission expires: «7-
•
'ctigM c0�N�y�`�� Nota Public

NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory John E. Skvarla, Ill
Governor Secretary •
November 6, 2014
Ms. Nicole T. Goad
166 Forestdale Drive
Reidsville, NC 27320
Subject: Compliance Evaluation Inspection
Certificate of Coverage: NCG550200
166 Forestdale Drive, Reidsville
Rockingham County
Dear Ms. Goad:
On November 4, 2014, Jenny Graznak of this office performed a Compliance Evaluation Inspection
on the General Permit to discharge domestic wastewater from the single family residence located at
166 Forestdale Drive in Reidsville, NC. According to county records, you are the current owner of
this property. No one was home at the time of the inspection.
A file review revealed that this permit is still listed under the previous owner's name: William N.
Parks. You will need to complete and return a Permit Name/Ownership Change Request, which can
be found at the following web address: http://portal.ncdenr.orq/web/wq/swp/ps/npdes/forms.
The inspector observed two chlorinator tubes as well as the discharge pipe. The caps were tightly
screwed on, and the inspector was unable to check for the presence of chlorine in the tubes. Please
be aware that the Permit requires that the chlorinator be adequately supplied with chlorine tablets for
proper operation. The Permit also requires that the septic tank contents be pumped out every five
years to prevent solids from clogging the sandfilter system. The discharge pipe was located in a dry
ditch behind the home. No discharge was observed.
A copy of all of the Permit requirements, including monitoring requirements, can be found on our
website: http://www.ncwater.orq. Please contact Ms. Graznak at [phone] in order to discuss
the ownership change requirement for your permit.
Sincerely,
W. Corey Basinger, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources
cc: WSRO RECEIVEDIDENRIDWR
Charles Weaver, NPDES Unit
NOV 1 4 ZU14
ual
N.C.Division of Water Resources/Winston-Salem Regional Office Water g Sy
P
450 W.Hanes Mill Road,Suite 300,Winston-Salem,NC 27105 ermKtirt9 Secction
Phone:[phone] Internet:www.ncwater.org
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