NCG550289_Owner (Name Change)_20171027

PAT MCCRORY
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�` DONALD R. VAN DER VAART
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F�E� lV ED/2 7
S. JAY GIivIMERMAN
Water Resources `J.Jatei (,)uaiit}!
ENVIRONMENTAL QUALITY Pen-n9t+,thng .. rCllon
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCO() / / / / or NCG55 O/Q/p/6
1. Facility Name: cr ` OG, ea zinvie,�( "2'73
II. NEW OWNER/NAME INFORMATION:
1. /This request for a name change is a result of:
V a. Change in ownership of property/company
b. Name change only j1
c. Other(please explain): t4 /11
2. New owners name (name to be put on permit): ,.�Ul�
`\\Ne_A nH e n
3. New owner's or signing official's name and title: `I\Ne\ SSG, E�1 n t c r*
(Person legally response le fordDermit)
(Title)
4. Mailing address: 3100 C— .\er ra, pe;,, --eCitCity:'�v�
State: MC-- Zip Code: e -7 3W0 Phone: ( S(AD
E-mail address:
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
[see reverse side of this page for signature requirements]
State of North Carolina I Environmental Quality 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

NPDES Name&Ownership Change
Page 2 of 2
Applicant's Certification: /� /) _
I, 1 ... 0AL4't. `��/J � , attest that this application for a
n me/ownership change has been reviewe,)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 and attachments are not included, this application
package will be returned as incomplete.
Signature: , Lu U_Y,e/y6+1,-) Date: / / i1 ( V/7
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS.,-SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
17NC DEQ/ DWR/ NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 7/2016

• I
United States Environmental Protection Agency Form Approved.
EPA Washington,D.C.20460 - OMB No.2040-0057 - -
Water Compliance Inspection Report Approval expires 8-31-98
Section A:National Data System Coding(i.e.,PCS)
Transaction Code NPDES yr/mo/day Inspection Type Inspector Fac Type
1 E 2 [ I 3 I NCG550289 111 12 I 17/09/28 117 18 i,.i 19 i 2 201 1
21I111 I I I I I III I I I I I I I I I I I I I I I I I I I I I I III I I I I I r6
Inspection Work Days Facility Self-Monitoring Evaluation Rating B1 QA — -Reserved
671 I 70I LJ it
I 71I I 72 1 I 1 731
I 174
751 I I I I I I I80
Section B:Facility Data
LJ l
Name and Location of Facility Inspected(For Industrial Users discharging to POTW,also include Entry Time/Date Permit Effective Date
POTW name and NPDES permit Number) 09:35AM 17/09/28 13/08/01
223 Mount Carmel Church Road
Exit Time/Date Permit Expiration Date
223 Mt Carmel Church Rd
09:50AM 17/09/28 18/07/31
Ruffin NC 27326
Name(s)of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s) Other Facility Data •
///
Name,Address of Responsible Official/Title/Phone and Fax Number
Contacted
Georgie Wclifton,223 Mt Carmel Church Rd Ruffin NC 27326//919-939-7707/
No
Section C:Areas Evaluated During Inspection(Check only those areas evaluated)
II Permit II Operations&Maintenance II Facility Site Review Effluent/Receiving Waters
Section D:Summary of Finding/Comments(Attach additional sheets of narrative and checklists as necessary)
(See attachment summary)
Name(s)and Signature(s)of Inspector(s) Agency/Office/Phone and Fax Numbers Date
Paul DiMatteo WSRO WQ//336-776-9691/
7� hihdp /0I31'(7
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
EPA Form 3560-3(Rev 9-94)Previous editions are obsolete.
Page# 1

NPDES yr/mo/day Inspection Type (Cont.) 1
31 NCG550289 111 121 17/09/28 117 18 I_I
Section D:Summary of Finding/Comments(Attach additional sheets of narrative and checklists as necessary)
Site Review
The system consists of a septic tank, subsurface sand filter, chlorinator, and outfall,with final
disposal to Quaqua Creek. No sewage malfunction was observed at or around the septic tank.
Chlorine appeared to be present in the chlorinator. The outfall was unable to be located during the
inspection—the resident pointed to an area that was overgrown with vines whereas Ms. Clifton said
that the outfall line went to the creek further down the road. Both Ms. Clifton and the resident said that
the outfall was observed occasionally and that water discharges from it; however, Ms. Clifton said that
no annual monitoring has been conducted to date.
Please note that annual effluent monitoring is required as stated in Part I.A of the Permit.
Additionally,the chlorinator should also be checked weekly to ensure an adequate supply of chlorine
disinfection tablets.Tablets should only be used if they are indicated for wastewater disinfection.
Finally, Rockingham County tax records identify Melissa Clifton Seal as the current owner of this
property. However, the Certificate of Coverage was issued to Georgie Clifton. Please complete and
return the attached "Permit Name/Ownership Change Form"so that the CoC may be updated.
Documentation & Monitoring Review
A review of documentation was not conducted at the time of inspection.We would like to remind
you to conduct and document the following:
- Effluent monitoring must be performed as required in the permit.
- All system components must be maintained at all times and in good working order.
- Inspect the septic tank and secondary tanks at least yearly to determine if solids must be removed.
- Pump the septic tank every 5 years, or when the solids level is found to be more than 1/3 of the
liquid depth in any compartment,whichever is greater.All tanks should be emptied of their contents
whenever any of the tanks meet this requirement.
- Contents removed from septic tanks shall be disposed of at a location and in a manner
compliant with all local and state regulations.
- Inspect the outfall location at least twice per year to ensure that no visible solids or other obvious
evidence of system malfunctioning is observed.
- Inspect the tablet chlorinator(if applicable) at least weekly to ensure there is an adequate supply of
tablets for continuous&proper operation. Tablets used for chlorination must be labeled for wastewater
use.
- Any monitoring data obtained shall be retained onsite for a minimum of 5 years.
- Additional requirements as stated in NCG550000.
Page# 2

•1
•
Permit: NCG550289 Owner-Facility: 223 Mount Carmel Church Road
Inspection Date: 09/28/2017 Inspection Type:. Compliance Evaluation
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? • ❑ ❑ ❑
Does the facility analyze process control parameters,for ex: MLSS, MCRT,Settleable ❑ ❑ � ❑
Solids,pH, DO,Sludge Judge,and other that are applicable?
Comment:
Permit Yes No NA NE
(If the present permit expires in 6 months or less). Has the permittee submitted a new ❑ ❑ • ❑
application?
Is the facility as described in the permit? Si ❑ ❑ ❑
#Are there any special conditions for the permit? ❑ • ❑ ❑
Is access to the plant site restricted to the general public? II ❑ ❑ ❑
Is the inspector granted access to all areas for inspection? • ❑ ❑ ❑
Comment:
Page# 3

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A 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.
,_S > L6t- (SEAL)
Geclrgie Stone Clifton
NORTH CAROLINA, Rockingham County.
I. 'LY�i, 54—i ,t , a Notary Public of said County and State aforesaid.
certify that Georgie Stone Clifton, Grantors. personally appeared before me this day and acknowledged
the execution of the foregoing instrument.
Witness my hand and official stamp or seal, thisc day of 3e4) . 2012.
...—/l/t( ',0t CvL
Notary Public f
My Commission Expires: 6a- 5 - 1
(SEAL/STAMP)
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Filed
Rockingham County, NC
Rebecca B. Cipriani, Register of Deeds
07/30/2012 09:34:21 AM
Fee Amt:$26.00 NC Excise Tax: $0.00
MITZI M. EVANS
NORTH CAROLINA GENERAL WARRANTY DEED
Revenue Stamps NTC .-
Mail after recording to '- GRANTEE, 223 Mount Carmel Church Rd., Ruffin, NC 27326
This instrument was prepared by t Matthew W. Smith
Brief description for the Index
SR 1914& 1925 -0.34 acs Tax Unique k 159124
THIS DEED made this VI day of l , 2012, by and between
GRANTOR GRANTEE
GEORGIE STONE CLIFTON MELISSA CLIFTON SEAL Et,kan14cui..\
aka Georgia Jeffries
separated
Address:
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«hich
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 Ruffin Township.Rockingham County.North
Carolina and more particularly described as follows:
BEGINNING at an iron stake on the north edge of the paved road leading from Oregon Hill to
Harrison's Cross Road, said stake marking a corner between Joe G. Kennon and jack Ellington
(formerly a part of the John Ellington lands); thence in a northerly direction with the line between
Joe G. Kennon and Jack Ellington 152 feet; thence a new line in an easterly direction parallel with
the said road leading from Oregon Hill to Harrison's Cross Road, 100 feet to a stake; thence a new
line in a southerly direction parallel with the Kennon-Ellington line, 152 feet to a point in the north
edge of said Oregon Hill-Harrison's Cross Road; thence with said road in a westerly direction 100
feet to the point of beginning,containing approximately 15,200 square feet. Being the same property
as described in Deed Book 812, page 921, Rockingham Counts Registry. For further reference. see
Book 675, page 32 and Book 653, page 507, Rockingham County Registry.