NCG551273_Renewal Application_20180530

PAT 18CCRORY
S..1AY ZININIERNMA N
RENEWAL FORM FOR EXISTING PERMITTED FACILITIES
NPDES 041WAi, application for tpq;1�; n C.0VjAqtt under General Permit NCG550000:
Certificate of Coverage NCG55 I �a7 -;
(Please verify the information in items 1 & 2 as correct, or note any corrections that should be made.)
(Please print or type)
RECEIVED/DENR/DWR
1) Mailing address' of property owner:
Owner Name A'1'MA N � L� MAY 3 0 2018
�RlJSNt '7L Water Resources
Street Address 10 �A Permitting Section
city P v am non ,
Telephone (Home) g Cj) (Mobile)
(e-mail address) l�C► /(,� ' l�lr �L�. �CX L�
2) Location of facility producing discharge*:
Street Address 10 6 ill 3 5v-1 PL-
City: —00 461 A E I l V C—
County Do (z-K -ftA
Telephone (Home)_ I IQ �t 6<-'`eQ O a— (Mobile)
3) Description of Discharge:
a) Type of facility producing waste (please check one):
Primary residence
❑ Vacation/second home
❑ Undeveloped property
❑ Other [describe]:
Page 1 of 2

NCG550000 renewal form
4) Please check the components that comprise the wastewater treatment system:
0 Septic tank ❑ Dosing tank 9 Primary sand filter 0 Secondary sand filter
❑ Recirculating sand filters) fd Chlorination ❑ Dechlorination
❑ Other form of disinfection: 0 Post Aeration (describe)
5) Other Information:
a) When was the septic tank last pumped out? Jor1C_ QO15
b) Is the facility [home] occupied year-round, or only seasonally? 1M(-fNR_d_
c) Approximately how many people use the facility when it is occupied? �3
d) When was the wastewater system installed? �lw�
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:
Applicant)
All -Lan R.mat)lWI
North Carolina General Statute 143-215.6 b (i) provides that:
�&, LY
(Date Signed)
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
Charles H. Weaver
NC DEQ / DWR / NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
to:
Page 2 of 2