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Home My WebLink AboutNCG550283_Permit (Issuance)_20070727 A • A 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 27, 2007 Jeffrey& Martha Brown 122 Rockford Rd Kernersville,NC 27284 Subject: Renewal of coverage/General Permit NCG550000 122 Rockford Road Certificate of Coverage NCG550283 Forsyth County Dear Permittee: In accordance with your renewal application [received on January 18, 2007],the Division is renewing Certificate of Coverage(CoC)NCG550283 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 toya.fields@ncmail.net] or Susan Wilson [919 733-5083,extension 510 or susan.a.wilson@ncmail.net]. Sincerely, for Coleen H. Sullins cc: Central Files Winston-Salem Regional Office I 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: 919 733-5083/FAX 919 733-0719/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 NCG550283 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, Jeffrey & Martha Brown is hereby authorized to discharge domestic wastewater [450 GPD] from a facility located at 122 Rockford Road Kernersville Forsyth County to receiving waters designated as an unnamed tributary to Belews Creek 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 August 1, 2007. This Certificate of Coverage shall remain in effect for the duration of the General Permit. Signed this day July 27, 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 NCG550283 (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: 2007 Owner Name Jeffrey Brown/m��Q,T3}A 820l.JJ AN 1 8 Ai Street Address 122 Rockford Rd Address Kernersville,NC 27284 Telephone (Home) 5%.=, 9, r 73S9 (Mobile) (e-mail address) 3 t'Yl z brc+,xw a e Ceti. er rn *Address to which all permit correspondence will be mailed 2) Location of facility producing discharge*: Facility ID Jeffrey Brown- Residence Address: 122 Rockford Rd, Kernersville,NC 27284 (Forsyth County) • Telephone (Home) 33 6- i°1 b-7359 (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): �d Primary residence ❑ Vacation/second home ❑ Undeveloped property 0 Other [describe]: 4) Pleasele check the components that comprise the wastewater treatment system: L�Septic tank ❑ Dosing�tannk ®'Primary sand filter 0 Secondary sand filter lfe'1.;0 Recirculating sand filter(s) hlorination 0 Dechlorination 0 Other form of disinfection: 0 Post Aeration(describe) Page 1 of 2 NCG550000 renewal form • 5) Other Information: �y a) When was the septic tank last pumped out? 6/—/5J— 6 / 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? '1 D c) Approximately how many people use the facility when it is occupied? 3 d) When was the wastewater system installed? /q 0 g- 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: I 4471W4 bg 0(-)-)iJ , A& w l-1 b--d7 (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 INVOICE INVOICE JETCO PUMPING SERVICE N2 13339 P.O. Box 1322 Rural Hall, NC 27045 - Phone- 766-0880.969-5022. 993-2411 Date: l ! /S 07 Name r1, 4/_2344..)-,) Address ) 2 Z �jCk�b�-� City, State, Zip Code �-V 1 j// 111 • Phone Amount Enclosed TO INSURE PROPER CREDIT,PLEASE RETURN THIS PORTION WITH YOUR PAYMENT DATE DESCRIPTION CHARGE CHECK BALANCE 1-1 S o7 fL--e 7 j/( 17S-v� I _ Thank:You. Total Pay To: JETCO PUMPING SERVICE P.O. Box 1322 Rural Hall, NC 27045 11/2%per month SERVICE CHARGE after 10 days.