NCG550183_Other_20121218

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Weaver, Charles
From:
Graznak, Jenny
Sent:
Tuesday, December 18, 2012 11:18 AM
To:
Weaver, Charles
Subject:
RE: I made NCG550183 Inactive in BIMS
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From: Weaver, Charles
Sent: Monday, December 1712012 2:00 PM
To: Graznak, Jenny
Subject: I made NCG550183 Inactive in BIMS
We received the annual fee invoice for this one, returned by Louise Barnes with the following handwritten note:
"This property has been sold. The permit fee is for a septic system that has not been in service for many years and has
been declared unusable by Alamance County. A new septic permit has been passed to the current owner and once that
system is installed the county will totally declare this old system defunct - the house it belongs to is gone.
Please do not send any correspondence to David Jessee who no longer owns this land. Call me @919 923 -3220 if you
have any questions."
If you think it should be reactivated for any reason, let me know.
And if I don't talk to you again this week — have a wonderful Christmas!
CHW

NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
INVOICE
Annual Permit Fee
IIII�IIINIIIII��NII IIIII II���
Overdue
This annual fee is required by the North Carolina Administrative Code. It covers the administrative costs associated
with your permit. It is required of any person holding a permit for any time (luring the annual fee period, regardless of
the facility's operating status. Failure to pay the fee by the due date will subject the permit to revocation. Operating
without a valid permit is a violation and is subject to a $10,000 per day fine. If the permit is revoked and you later
decide a permit is needed, you must reapply, with the understanding the perrnit request may be denied due to changes
in environmental, regulatory, or modeling conditions.
Permit Number: NCG550183
Alamance County
Pettv Road Rental House
David Jessee
106 C S Greensboro St
Carrboro, NC 27510
Annual Fee Period: 2012 -10 -01 to 2013 -09 -30
Invoice Date: 09/06/12
Due Date: 10/06/12
Annual Fee: $60.00
Notes:
1. A $25.00 processing fee will be charged for returned checks in accordance with the North Carolina General Statute 25 -3 -512
2. Non - Payment of this fee by the payment due date will initiate the permit revocations process.
3. Remit payment to:
NCDENR - Division of Water Quality
1617 Mail Service Center
Raleigh, NC 27699 -1617
4. Should you have any questions regarding this invoice, please contact the Annual Administering and Compliance Fee
Coordinator at 9 9- 807 -6321.
C ,,�:v
QV
(Return This Portion With Check)
ANNUAL PERMIT INVOICE
2 0 1 2 P R 0 0 9 0 8 7
. t A Overdue
IV
Permit Number: NCG550183 Annual Fee Period: 2012 -10 -01 to 2013 -09 -30
Alamance County
Invoice Date: 09/06/12
Petty Road Rental House
'JJ_
Due Date: 10/06/12
Annual Fee: $60.00
David Jessee
106 C S Greensboro St ' Check Number:
Carrboro, NC 27510

OF WATF9
�0� pG
_6
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H, Sullins, Director
Division of Water Quality
September 16, 2008
David and Karen Jessee
106 C South Greensboro Street
Carrboro, North Carolina 27510
Subject: General Wastewater Permit No. NCG550183 — Single Family Residence
Petty Road Rental House — Saxapahaw, North Carolina
Alamance County
Dear Mr. & Mrs. Jessee:
Jenny Graznak of the Winston -Salem Regional Office performed a Compliance Evaluation
Inspection on the wastewater treatment system at your property on Petty Road in Alamance County,
North Carolina on September 15, 2008. This type of inspection consists of two basic parts: a review
of self- monitoring data, and an on -site inspection of the facility and its discharge. No one was home
during Ms. Graznak's visit to your property. Attempts to contact you to schedule an inspection were
unsuccessful.
You hold a General Permit to discharge Domestic 'Wastewaters from Single Family
Residences under the National Pollutant Discharge Elimination System ( NPDES). The discharge
from this system flows to Haw River. Permit text Part I Section A (attached to this correspondence)
specifies the limits and monitoring requirements for your permit. The following parameters must be
monitored on an annual basis: Flow, Biochemical Oxygen Demand (BOD), Total Suspended
Residue, Fecal Coliform, and Total Residual Chlorine. A Laboratory with North Carolina Wastewater
Certification (a list of approved laboratories is attached) must perform this monitoring. You must
also conduct and document the following maintenance activities:.
• Septic tanks shall be maintained at all times to prevent seepage of sewage
• Septic tanks will be checked at least yearly to determine if solids must be removed
• Septic tanks shall be pumped out within 3 -5 years of issuance date of the Permit.
Contents removed from septic tanks shall be disposed of at a location and in a manner
compliant with all local and state regulations
According to our files, the wastewater system at your property on Petty Road consists of a
1,000- gallon septic tank, a subsurface sandfilter, and a discharge pipe. There is no chlorination unit
on this system due to its age. Our files show the discharge pipe located just below the Haw River
dam at Saxapahaw. However, Ms. Graznak could not locate the pipe during her inspection. Please
contact Ms. Graznak at (336) 771 -4960 at your earliest convenience to discuss this inspection.
Sincerely,
Steve W. Tedder
Regional Supervisor
Surface Water Protection Section
cc: SWP — Central Files
SWP — WSRO
NPDES Unit
Aturall'y neCarolina
North Carolina Division of Water Quality 585 Waughtown Street Winston Salem, NC 27107 Phone [phone] Customer Service
Internet: hftp: / /h2o.enr.state.nc.us FAX [phone]
An Equal Opportunity /Affirmative Action Employer — 50% Recycled /10% Post Consumer Paper

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 1 NI 2 1 51 31 NCG550183 1 11 121 08/09/15 1 17
18) c) 191 SI 201 1
Remarks
21111 111111111111 11111111 111111111111
1111 IIII Ill6
Inspection Work Days Facility Self- Monitoring Evaluation Rating B1 QA
-------------------------- Reserved---------------- - - - - --
671 169 701 1 711 1 721 N I
73' I 174 751 1 1 1 I l I 180,
W
Section B: Facility Data
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)
11:00 AM 08/09/15
07/08/03
Petty Road Rental House
Exit Time /Date
Permit Expiration Date
Petty Rd
Saxapahaw NC 27340
11:30 AM 08/09/15
12/07/31
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
David Jessee,106 C S Greensboro St Carrboro NC 27510//919 -548 -6408/ No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit 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
Jennifer F Graznak WSRO WQ//336- 771 -5000/
Signature of anagement Q A sewer Agency /Office/Phone and Fax Numbers Date
rlo�
EPA Form 3560 -3 (Rev 9 -94) Previous editions are obsolete.
Page # 1

Permit: NCG550183
Inspection Date: 09/15/2008
Owner - Facility: Petty Road Rental House
Inspection Type: Compliance Evaluation
Permit
(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? .
# Are there any special conditions for the permit?
Is access to the plant site restricted to the general public?
Is the inspector granted access to all areas for inspection?
Comment:
Effluent Pipe
Is right of way to the outfall properly maintained?
Are the receiving water free of foam other than trace amounts and other debris?
If effluent (diffuser pipes are required) are they operating properly?
Comment: Ms. Graznak could not locate the pipe during her inspection
❑ ❑ ■ ❑
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Page # 3

of W a rFq Michael F. Easley. Governor
William G. Ross Jr., Secretary
r North Carolina Department of Environment and Natural Resources
'C Coleen H. Sullins, Director
Division of Water Quality
December 31, 200"
DAVID IESSEE
KAREN JESSEE
106 C S GREENSBORO ST
CARRBORO NC 27510
Subject: NPDES Permit Modification- Ownership Change
Petty Road Rental House
Certificate of Coverage NCG550183
Alamance County
Dear Mr. & Mrs. Jessee:
Division personnel have reviewed and approved your request for ownership change of the subject certificate of
coverage received on December 21, 2007. This permit modification documents the change of ownership of the
above reference facility.
Please find enclosed the revised certificate of coverage. All other terms and conditions contained in the original
certificate remain unchanged and in full effect. This modification is issued under the requirements of North Carolina
General Statutes 143 -215.1 and the Memorandum of Agreement between North Carolina and the U.S. Environmental
Protection Agency.
If you have any questions concerning this permit modification, please contact the Point Source Branch at (919)
733 -5083, extension 350.
Sincerely,
p�Coleen H. Sullins
cc Central Files
Winston -Salem Regional Office, Surface Water Protection
NPDES Unit File NCG550183
N:of hCarolina
Aatumllu
North Carolina Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 Phone [phone] Customer Service
Internet h2o.enr.state.naus 512 N. Salisbury St. Raleigh, NC 27604 FAX [phone]
An Equal Opportunity/Affirmative Acton 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 NCG550183
TO DISCHARGE DOMESTIC WASTEWATERS 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,
DAVID JESSEE
is hereby authorized to discharge domestic wastewater [500 GPD] from a facility located at
Petty Road Rental House
Saxapahaw
Alamance County
to receiving waters designated as the Haw River in subbasin 03 -06 -02 of the Cape Fear River Basin in
accordance with the effluent limitations, monitoring requirements, and other conditions set forth in Parts 1, 11, III,
and IV of General Permit No. NCG550000 as attached.
This certificate of coverage shall become effective January 4, 2008.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day January 4, 2008.
cA da2��
oleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission

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State of North Carolina Lc,
�� F d1Y
Department'of Environment •
and Natural Resources DEC 2
Y 1 2007
Division of Water Quality
DHt R - WATLR /Q�UALITY
Michael F. Easley, Governor f ;,II,;; �;��JI �/I'Al%Cfq _ C ENR,
�r�
William G. Ross, Jr., Secretary - µ .. ��� _ _.__ —NORTH CAROLINA DEPARTMENT OF
Coleen H. Sullins, Director ENVIRONMENT AND NATURAL RESOURCES
PERMIT NAME /OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION: $ O` ,
Permit Number: NC00 / / 3
GSS S
1 Permit holder's name To HN A . ^D�
2 Permit's signing official's name and title ®NKI Q eat
(Person legally respombe for permit)
(Title)
3 Mailing address /moo y /VATioA1AL A VE City _ AJew 3£A!w
State- Zip Code: Z&5:( ,ca Phone: (152 ) 4 3 8 —S'1 713
E -mail address h9A-N2> D L/ Av /r- , NE. T
II. NEW OWNER/NAME INFORMATION:
1 This request for a name change is a result of
- - -a Change in ownership of property /company
b. Name change only
c Other (please explain):
2 New owner's na (name . to be put on permit)
3 New owner's or signing official's name and title:
(Person legally responsi-161 for permit)
Di .I ►,. (�n�
(Title)
4 Mailing address 16 tee+, -L OV-0 `A" City C-o_V*Ly0
State k-- Zip Code- Z"?� 10 Phone: (1 (9 ) 25- `f e— 6 y
0
E -mail address
1617 Mad Service Center, Raleigh, North Carolina 27699 -1617
An Equal Opportunity Affirmative Action Employer
ufi=
Telephone [phone] FAX [phone]
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PERMIT NAME / OVI NERik R CHANGE FORM
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION OF WATER QUALITY 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 contract, deed, articles of
incorporation)
For changes of ownership, this form must be completed and signed by both the current permit
holder and the new owner of the facility.
For name change only, the current permit holder must complete and sign the Applicant's
Certification.
Current Permittee's Certification:
11 7600 , attest that this application for
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 and attachments are not included, this application
package will be returned as incomplete.
Signature: - ' Date �� a
Applicant's Certification:
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 and attachments are not included, this application
ackage W)II be returned as�inprnplete.
a
`�
-� t nature: t Date: I 2-1t C� 6 �
THE COMPLETED APPLI A4 ION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATER 'S, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DENR / DWO / Point Source Branch
1617 Mail Service Center
Raleigh, North Carolina 27699 -161,7
Version 8101

E E E
DEC 2 1
2007 -
DEf�^ - WATEP QUALITY
o Z -7
Doc ID: 3 1111111111111 III IIIII IIIII IIIII IIIII IIIII IIIII I II
Iiillllllllllllllllllllllllll
Recorded: 111/16/200700atT03:22:50 PM
Fee Amt: $240.00 Page i of 3
Excise Tax: $220.00
Alamance, NC
DAVID J.P. BARBER REGISTER OF DEEDS
BK2645 PG216 -218
D E E D
Prepared by: .
Richardson & Richardson
Ernest C. Richardson, III i ms Parcel ID: 9709397106
PO Box 1594
New Bern, NC 28563 Whole
(252) 633 -2470 No Title Examination Performed
Return to Grantee at address below
NORTH CAROLINA
ALAMANCE COUNTY
_ st
THIS DEED, made this the 3) day of u i- , 2007, by and between John
A. Delk and wife, Roberta Delk (herein called the "Grantor "); and David Jessee whose address is
*and wife, Karen Jessee, 532 Seaforth Rd., Pittsboro, NC 27517 (herein
called the "Grantee "). The designation Grantor and Grantee as used herein shall include the parties
indicated, and their respective heirs, successors, legal representatives, and assigns, and shall include
singular, plural, masculine, feminine or neuter as required by the context.
W IT`NTESS%TH:
That the Grantor, for and in consideration of Ten Dollars ($10.00) and other good and
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
tract of land lying in Newlin Township, Alamance County, North Carolina, and being more
particularly described as follows:
M

simple; has the right to convey the same in fee simple, that title is marketable and free and clear of all
encumbrances, except as described above, and that Grantor will warrant and defend the title against
the lawful claims of all persons whomsoever.
IN WITNESS WHEREOF, the Grantor has signed and sealed this deed the day and year first
above written.
G. ` (SEAL)
Jo A. Delk
C' eL (SEAL)
Roberta Delk
NORTH CAROLINA
CRAVEN COUNTY
I, COro\e. �.. �e n c--t- , a Not Public in and for said Count and State,
�Y Y
do hereby certify that John A. Delk and wife, Roberta Delk personally appeared before me this
day and acknowledged the due execution of the foregoing instrument.
"WITNESS my hand and official stamp or seal, this ' day of
2007. Ij
w',`,�''i
,.• ... Ric'%
3 J s Notary Public
ALPU ^ �`v, . •� ', d My Commission Expires: tlj 2 t 2 U o
,iii • Q • • , , . • , � �
CO'V,,,...�'��
ieouu

Tract One:
That certain tract or parcel of land in Newlin Township, Alamance County, North
Carolina, adjoining the lands of Saxapahaw Mills' land and others and bounded as
follows:
BEGINNING at a rock, corner with Saxapahaw Mills' land on the south bank of Haw
River and running thence South 73° West 9.80 chains to a rock, corner with Lizzie
Cooper in the line of said Mills' lands; thence North 15° West 5.40 chains to a rock,
corner with said Cooper; thence South 74 -3/4° West 7.35 chains to an iron bolt,
corner with said Cooper and Edwards in road to Saxapahaw, North Carolina; thence
North 28° East 13.20 chains to a rock, corner with said Edwards on the south bank of
said river; thence down said river as it meanders, South 34° East 4 chains, South 42-
1/2° East 11.17 chains, South 74° East 1.86 chains to the BEGINNING, and
containing 10 acres, more or less, and being Lot No. One (1) of the division of the A.
G. Cooper lands and was sold to Nettie Cooper by W. I. Ward and J. H. Vernon, and
at her death descended to Daisy Cooper Rogers.
Tract Two:
All that certain tract or parcel of land located in Newlin Township, Alamance
County, North Carolina, adjoining the lands of Lonnie Curl, Jr., Dwight K. Ratts,
Floyd M. Petty, and S. R. #2173, and bounded and described as follows:
BEGINNING at an iron stake in the north margin of the right of way of S. R. #2173,
a common corner with Lonnie Curl, Jr. and Floyd M. Petty, and running thence with
the line of Lonnie Curl, Jr., Floyd M. Petty and Dwight K. Ratts,, North 77° 26' 45"
East 46.38 feet to an iron stake in the line of Dwight K. Ratts (iron stake set in this
line 2.59 feet from Point of Beginning, which said iron stake is located at the
southwest corner of the property of Dwight K. Ratts and is a common corner between
said Ratts and Lonnie Curl, Jr. and in the line of Floyd M. Petty); running thence a
new line with Floyd M. petty South 37° 08' 35" West 35.37 feet to an iron stake in
the north margin of the right of way of S. R. #2173, a new corner with Floyd M.
Petty; running thence with the North margin of the right of way of S. R. #2173 North
52° 51' 20" West 30.00 feet to the Point of BEGINNING, and containing 0.01 acres,
more or less, as shown by survey made by David Thompson, Registered Land
Surveyor, dated April 3, 1981.
TO HAVE AND TO HOLD, the aforesaid tract of land together with privileges and
appurtenances thereunto to the Grantee in fee simple forever.
And the Grantor covenants with the Grantee, that the Grantor is seized of the premises in fee

1
0­4
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Michael F. Easley, Governor
August 3, 2007
John. A. Delk
1404 National Ave
New Bern, NC 28560
William G. Ross, Jr., Secretary
Coleen H. Sullins, Director
Subject: Renewal of coverage / General Permit NCG550000
Petty Road rental house
Certificate of Coverage NCG550183
Alamance County
Dear Permittee:
In accordance with your renewal application [received on January 30, 2007], the Division is renewing
Certificate of Coverage (CoC) NCG550183 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
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
An Equal Opportunity /Affirmative Action Employer - 50% Recycled/10% Post Consumer Paper
No hCarolina
,Xaturally

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NCG550000
CERTIFICATE OF COVERAGE NCG550183
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,
John A. Delk
is hereby authorized to discharge domestic wastewater [500 GPD] from a facility located at
Petty Road rental house
Saxapahaw
Alamance County
to receiving waters designated as the Haw River in subbasin 03 -06 -02 of the Cape Fear 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 3, 2007.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day August 3, 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 NCG550183
(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: �. r
� JAN 3 0 20[x/
Owner Name John A Delk /
ry
Street Address 1404 National Ave
Address
Telephone
(e -mail address)
New Bern, NC 28560
(Home) , 5 2
(Mobile) 2-5Z 3 `/= - 4:, 0 r' 5
?D1WDD P) iti is ��
* Address to which all permit correspondence will be mailed
2) Location of facility producing discharge`:
Facility ID Delk John- Residence
Address:
Telephone
NCSR 2173,
Saxapahaw, NC 27340 (Alamance County)
(Home) _ .1 -52 — — 3 (Mobile) zSZ 3 'lq -- 6c-'C . "
* 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
p Vacation/second home
,>\ ndeveloped property
❑ Other [ describe]: A- g Ls_S2_ �-l►�S ►�o_� -5 Ejno L I V -g D 1 -5z h.,
4) Please check the components that comprise the wastewater treatment system:
,(Septic tank ❑ Dosing tank ❑ Primary sand filter X 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:
a) When was the septic tank last pumped out? /%IRX
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? /L'/U
c) Approximately how many people use the facility when it is occupied?
d) When was the wastewater system installed? /?9 2
6) Certification:
J
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:
J&_
To
6/- /Z - G
(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

State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
Michael F. Easley, Governor
William G. Ross Jr., Secretary
Alan W. Klimek, P.E., Director
July 26, 2002
JOHN A DELK
DELK JOHN- RESIDENCE
1404 NATIONAL AVE
NEW BERN, NC 28560
�&L14�?WA
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
Subject. Reissue - NPDES Wastewater Discharge Permit
Delk John- Residence
COC Number NCG550183
Alamance County
Dear Permittee
In response to your renewal application for continued coverage under general permit NCG550000, the Division of
Water Quality (DWQ) is forwarding herewith the reissued wastewater general permit Certificate of Coverage
(COC) This COC is reissued pursuant to the requirements of North Carolina General Statute 143 -215 1 and the
Memorandum of Agreement between the state of North Carolina and the U S Environmental Protection Agency,
dated May 9, 1994 (or as subsquently amended)
The following information is included with your permit package
* A copy of the Certificate of Coverage for your treatment facility
* A copy of General Wastewater Discharge Permit NCG550000 `
* A copy of a Technical Bulletin for General Wastewater Discharge Permit NCG550000
Your coverage under this general permit is not transferable except after notice to DWQ The Division may require
modification or revocation and reissuance of the Certificate of Coverage This permit does not affect the legal
requirements to obtain other permits which may be required by DENR or relieve the permittee from responsibility
for compliance with any other applicable federal, state, or local law rule, standard, ordinance, order, judgment, or
decree
Please note that effective January 1, 1999 the fees for all permits issued by DWQ were changed This changed the
fee for your wastewater general permit coverage from a $240 fee paid once every five years to a yearly fee of $50
If you have not already been billed this year for the yearly fee, you will receive a bill later this year
If you have any questions regarding this permit package please contact Mack Wiggins of the Central Office
Stormwater and General Permits Unit at (919) 733 -5083, ext 542
Sincerely,
for Alan W Klimek, P E
CC. Central Files
Stormwater & General Permits Unit Files
Winston -Salem Regional Office
1617 Mall Service Center, Raleigh, North Carolina 27699 -1617 Telephone 919 - 733 -5083 FAX 919 - 733 -0719
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 NO. NCG550000
CERTIFICATE OF COVERAGE No. NCG550183
TO DISCHARGE DOMESTIC WASTEWATERS FROM SINGLE FAMILY RESIDENCES
AND OTHER 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,
JOHN DELK
is hereby authorized to operate a domestic wastewater treatment facility which includes a septic tank, sand filter,
and associated appurtenances with discharge of treated domestic wastewater from the facility located at
DELK JOHN - RESIDENCE
NCSR 2173
SAXAPAHAW
ALAMANCE COUNTY
to receiving waters designated as the Haw River, a class C water, to the Cape Fear River Basin in accordance
with the effluent limitations, monitoring requirements, and other conditions set forth in Parts I, II, lII, and IV of
General Permit No NCG550000 as attached.
This certificate of coverage shall become effective August 1, 2002.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day July 26, 2002.
for Alan W Klimek, P E., Director
Division of Water Quality
By Authority of the Environmental Management Commission

State of North Carolina
Department of Environment,
Health and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Wayne McDevitt, Secretary
A. Preston Howard, Jr., P.E., Director
John A. Delk
1404 National Avenue
New Bern, NC 28560
Dear Permittee:
LTI'MI�VA
�r
�EHNR
July 21, 1997
Subject: Certificate of Coverage No. NCG550183
Renewal of General Permit
Delk, John - Residence
Alamance County
In accordance with your application for renewal of the subject Certificate of Coverage, the Division is forwarding
the enclosed General Permit This renewal is valid from the effective date on the permit until July 31, 2002. This
permit is issued pursuant to the requirements of North Carolina General Statute 143 -215 .1 and the Memorandum of
Agreement between North Carolina and the U.S. Environmental Protection Agency dated December 6, 1983. If any
parts, measurement frequencies or sampling requirements contained in this 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, this Certificate of Coverage shall be final and binding.
The Certificate of Coverage for your facility is not transferable except after notice to the Division Use the enclosed
Permit Name /Ownership Change form to notify the Division if you sell or otherwise transfer ownership of the
subject facility. The Division may require modification or revocation and reissuance of the Certificate of Coverage.
If your facility ceases discharge of wastewater before the expiration date of this permit, contact the Regional
Office listed below at (910) 771 -4600. Once discharge from your facility has ceased, this permit may be rescinded.
This permit does not affect the legal requirements to obtain other permits which may be required by the Division of
Water Quality, 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 this permit, please contact the NPDES Group at the address below
Sincerely,
Y
cc: Central Files A. Preston Howard, Jr., P.E.
Winston -Salem Regional Office
NPDES Group
Facility Assessment Unit
P O Box 29535, Raleigh, North Carolina 27626 -0535 (919) 733 -5083 FAX [phone] p &e @dem ehnr state.nc.us
An Equal Opportunity Affirmative Action Employer 50% recycled / 10% post- consumer paper

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCG550000
CERTIFICATE OF COVERAGE NO. NCG550183
TO DISCHARGE DOMESTIC WASTEWATERFROM SINGLE FAMILY RESIDENCES
AND OTHER 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,
John A. Delk
is hereby authorized to operate a wastewater treatment facility which includes a septic tank, sand filter
and associated appurtenances with the discharge of treated wastewater from a facility
located at
Delk, John - Residence
NCSR 2173
Saxapahaw
Alamance County
to receiving waters designated as subbasin 30602 in the Cape Fear River Basin
in accordance with the effluent limitations, monitoring requirements, and other conditions set forth
in Parts I, II, III and IV of General Permit No. NCG550000 as attached.
This certificate of coverage shall become effective August 1, 1997.
This certificate of ,coverage shall remain in effect for the duration of the General Permit.
Signed this day July 21, 1997.
A. Preston Howard, Jr., P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission

Let'p-.r tcrJOHN A. DELK
NCG550183
May 1, 1997
INVOICE FOR RENEWAL OF
NPDES PERMIT
Check here if you do NOT wish to renew this permit.
Please return this page along with a letter documenting your reasons
for not requesting renewal to:
Mr. Charles H. Weaver, Jr.
Division of Water Quality /WQ Section
NPDES Group
Post Office Box 29535
Raleigh, North Carolina 27626 -0535
Check here if you wish to renew this permit.
/9
Please verify that the following information is documented accurately:
Mailing Address
JOHN A. DELK
DELK, JOHN - RESIDENCE
1404 National Avenue
NEW BERN, NC 28560
Phone number: (919) 638 -5123
Fax number:
e -mail address:
Facility Location
JOHN A. DELK
DELK, JOHN - RESIDENCE
SR 2173
SAXAPAHAW, NC 27302
❑ No revision required.
Revision required. (Please specify below.)
❑ No revision required.
❑ Revision required. (Please specify below.)
Please return this page with your letter requesting renewal, and $240 fee (payable to NCDEHNR) to:
Mr. Charles H. Weaver, Jr.
Division of Water Quality /WQ Section
NPDES Group
Post Office Box 29535
Raleigh, North Carolina 27626 -0535
Signature of applicant or authorized representative l�
Date _,� '.0 9'J
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