NCG550722_Renewal Application_20180426

PAT MCCRORY
diol el iJol
y r DONALD R VAN DER VAART
43p ._ `'• - ,,,
Sec;elm v
WaterResaua ces S JAY ZIMMERMAN
ENVIRONMENTAL OUALIVY Du cm)
RENEWAL FORM FOR EXISTING PERMITTED FACILITIES
NPDES renewal application for continued coverage under General Permit NCG550000:
Certificate of Coverage NCG55
(Please verify the information in items 1 &2 as correct, or note any corrections that should be made.)
(Please print or type) r �CElVED1D �1 ID�1►�
1) Mailing address* of property owner: APR 6 2098
Owner Name Clw,S'00• 4-- �• <( 5
water Resources
� -` � � Permitting Section
Street Address �� \`� (;t�OV%; l��t zx� ` •
City ,EU_ ) (C.,0-M34GI/
Telephone (Home) ° 4 (030'-9 l y (Mobile) 2(A—(030— 9(f '7
(e-mail address) , e-C-.1\11C yaLco. cDIA
*Acicliess to which all permit correspondence will be mailed
2) Location of facility producing discharge*:
Street Address cd L'c.
City. -RA's-1 cg
County 7—ex.(v..c.Q,A. -Q
Telephone (Home)g cA b (Mobile) (`4A—L, ?0 •— � l
*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).
1/Primary residence
❑ Vacation/second home
❑ Undeveloped property
❑ Other [describe]
Page 1 of 2

NCG550000 renewal form
4) Please� check the components that compriserithe wastewater treatment system:
Lf Septic tank 0 Dosing tank 1'Primary sandfifi ter 0 Secondary sand filter
O Recirculating sand filter(s) f5 Chlorination f f echlormation
O Other form of disinfection: 0 Post Aeration (describe)
5) Other Information:
a) When was the septic tank last pumped out? I(-041 i
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? rcr m4+4
c) Approximately how many people use the facihty when it is occupied? 3
d) When was the wastewater system installed? I 99% 7 ev- Clqg
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 SigningC/1 rtS1-0 ;A"�'/t`- N f`C I iS
41t3
( a. ature of plicant) (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:
Charles H. Weaver
NC DEQ / DWR/NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
Page 2 of 2

ifr
James & James Environmental Management
3801 Asheville Hwy., Hendersonville,NC 28791
OFFICE: [phone] FAX: [phone]
NC Certified Laboratory NC wastewater#482 NC Drinking Water#37763
March 29, 2018
Mr. Chris Nichols
23 Meadow Brook Drive
Fletcher, NC 28732
RE: Annual Test Results
Dear Mr. Nichols,
Enclosed are the results of the analysis performed by our staff on your samples The
analysis performed conform to Standard Methods 18th Edition.
Sample Analysis Method Result Units MDL Date run Analyst
C1918 FECAL 9222D <10 mg/L 1.0 03-19-18 DJ
C1918 TSS 2540D <3.09 mg/L 1.0 03-21-18 DJ
C1918 BOD 5210B 5 37 mg/L 2.0 03-21-18 LS
Chlorine Residual 0.1 mg/L
Flow (Estimate) 0.002 MGD
pH 6.0
Temperature 13.4
All of your results were within the allowable State limits. Should you have questions
regarding these results please feel free to contact us.
Thank you,
Trish Bryan
Administrative Assistant
James &James Environmental
jjenv@ bellsouth.net
828-697-0063

JJEM AQUEOUS SAMPLE COLLECTION/LAB REPORT FORM (NC CERT 482)
Regulated by NCDENR/DWQ-Groundwater section
To assign test,label shaded area with sample type(C=composite,G=grab)
CHAIN OF CUSTODY
!LOCATION CHRIS NICHOLS COUNTY BUNCOMBE SPECIAL INFORMATION(S)
E FLLIENT
/Ilf- f-td C-^--
ID NO. C1CI 1(j r I��r �l< 0INITIAL TEMP °C of 1 L
GRAB sample
time 1 ONCE A YEAR
COMP start
sample time 31-Mar
COMP end date/
time ''
®� r i (ot/U -(ji(s
COOLER#1 COOLER#2
TEMP @RECEIPT `-) `C T:.MPR=:.E PT' VC
NOTE THE ABOVE-EMP INDICATES-HE-EMP NOTE THE ABOVE TEMP INDICATES THE TEMP
=OR AL_ Co- A:NER; J n v FOR A_L CO\TP, NERCS) WITHIN
AMMONIA SAMPLES PRESERVED WITH H2SO4 pH=<2 0 YES NO
AMMONIA SAMPLES NEUTRALIZED WITH Na,SO;, C1=< 0 1 SES NO
,FECAL SAMPLES PRESERVED WITH Na2SO3 CI=< 0 1 k"---YES NO
COLLECTS® BY_._..__1. . ` }
ALL SAMPLES COLLECTED AND P ESERVED AT TINE OF LOLL ECi ION IN,PLL S IC CONT AfhERS UNLESS LASTED OTHERWISE BY
RELINQUISHED BY DATE/TIME RECEIVED BY SPLIT SAMPLE(S)INFO
1 L'A_ 11'x, ' 3V 1 -1 I i t
7
,' yf I ,
ANALYSES RESULT EFF DATE (NIT'L
F. COLI cfu/100m1 G t..)1J•K) SIG I ICg J
`BOD ppm G 5 -1 c
3 - I a1\ l B LS
CHLORINE RESID. G 0,1 It_
FLOVV(ESTIMATE) , 1
Ll
I
1
,• •
By the above signature I certify that all information is accurate to the best of my knowledge
•
COMMENTS
means QC not met (bb=- 8--C

LL ABOUT PO BOX 1041 Hendersonville,NC 28793 INVOICE
111
i Plumbing:828-778-2425 Septic:828-778-2423
- fi), PLUMBING Fax:[phone] Fax:[phone] Start Date: l , /
r
' ii SEPTIC License#30796 License#NCS01303 End Date: wi 'I 1
JOB SiTE ADDRESS BILLING ADDRESS Sr.Technician
Customer Name Customer Name
Address TYPE OF SERVICE
City I St Lrp Phone# City yt lip I Phone tl
❑ Service 0 Estimate
PAYMENT 0 Owner ❑Tenant
❑Cash❑Check❑Billed Check#OR Credit Card Referral#- Auth Code 0 Residential
■ Commercial
1 DIAGNOSIS SERVICE AGREEMENT
I agree that the initial price quoted prior to the start of work does not include any
additional or unforeseen tasks.Nor materials which may be found necessary to
complete repairs or replacements I also agree to hold All About Plumbing&Septic or
its assigns harmless for parts deemed corroded,unusual or unreliable completion of
stated work to be done.I hereby authorize All About Plumbing&Septic to perform
proposed work and agree to all terms on all sides of this document and further
acknowledgement that this invoice is due upon receipt
--------- Authorized Signature
$
WARRANTY DESCRIPTION OF WORKEetintV
i_ Price ic Price S fANtiA}2D Completed
RATE work
1
eps. r*: A'rte' ,r ru x' •i-•' -' rok "K ,7 #toss,= rgi, 9,:r-sip,7`i ,,r yds a, , sri'u.;rte � ,777c� " '"4r rs .r' t�`r• r^.n 4`,i`,f rf o,", -.
Discharge"Garro driform_tion ,,e, , 4. �,V. ,( _ s
Se, tate T' le- Gallons of Septage:
DischaIge Location: Discharge Date.
eitrr"i I OU-L TO�LEAVE A REVIEWS!` 0_ 'rdt Message ' #` ti �`'°z�'° :_ -"z„
b C❑ Email Notificarrorr ,� r� ,a�, I $ $ 4
I do hereby state the above work has been done in a professional manner and meets all applicable codes.
Technician Signature X �y _ m____� SUB TOTAL { $
Acceptance of work performed I find the service and matenal performed and installed have been completed in accordance with this agreement I
agree to pay reasonable attorney fees,collection fees and court cost in the event of legal action pursuant to collection of amount due Subject to one
percent interest on thirty day past due account TOTAL $
Customer Signature X -