NCG550486_Renewal (Application)_20190517

PAT MCCRORY
cove,nor
DONALD R. VAN DER VAART
Sect etary
Water Resources S. JAY ZIMMERMAN
ENVIRONMENTAL QUALITY Director
RENEWAL FORM FOR EXISTING PERMITTED FACILITIES
NPDES r•newal application for tinued coverage under General Permit NCG550000:
Certificate of Coverage NCG55 0486
(Please verify the information in items 1 &2 as correct, or note any corrections that should be made.)
(Please print or type)
1) Mailing address*of property owner:
Owner Name P‘off.
Street Address 3014 1 \. AGOiZAKs1-,rE.L C�
City I�_, ti� , I4C 2W`2
Telephone (Home) 704 ‘?)2) S1('1 (Mobile) -1cL1 2O'O 1 Zt
(e-mail address) .r R 1 DOLC3 D,Q! L• CD AA
Address m which permit correspondence will be mailed
2) Location of facility producing discharge*:
Street Address 3 041 \Ja( )t)-g k.1,Er - C c r
City: 2A101?
County 'AS+°P3
Telephone (Home)_ 1°4 B2 - 5-1 I (Mobile) 7t°' BC'D_p1ZD
*If the facility is net yet constructed, give the street address or let number where the structure will be
Iona.
3) Description of Discharge: REGE1 /NCDEQ/DWR
a) Typepe of facility producing waste (please check one): MAY 17 2019
E3" Primary residence
Water Quality
❑ Vacation/second home Permitting Section
❑ Undeveloped property
❑ Other [describe]:
Page 1 of 2

NCG550000 renewal form
4) Please check the components that comprise the wastewater treatment system:
2/Septic tank 0 Dosing tank 2/Primary sand filter ❑ Secondary sand filter
0 Recirculating sand filter(s) 11Chlorination ❑ Dechlorination
0 Other form of disinfection: [‘Post Aeration(describe) R ti)•RA P ACC AVE.
5) Other Information:
a) When was the septic tank last pumped out? ,S ' '2011
NOTE: the septic ta.i k. must be pumped out at least once every 3-5 years
b) Is the facility [home] occupied year-round, or only seasonally? ('(C-S - uMO
c) Approximately how many people use the facility when it is occupied? 3
d) When was the wastewater system installed? J uL( I cI`t
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: �`(( r• Q k o O t.e )2,
(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 an, ,: e_1 of the recei;.t fair your ,l _st s tic service to:
Charles H. Weaver
NC DEQ/DWR/NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
Page 2 of 2

-System Owner System Location "`—
Riddle Sherry Primary Home
3041 Wagonwheel Court 3041 Wagonwheel Court
Belmont, NC, 28012 Belmont, NC, 28012
(704)-616-7322 x (704)-616-7322 x
Sherry Riddle / Home
Call to Confirm:
K-Zyme Approx.Gals: 0
Custom Clean Cust Home : No
Zabel Filter Service Type: Standard
Inspection/T5 Frequency :
Previous Serv:01/24/2017
Service Date Build Up .
FRI 02/03/2017 01:00 PM Depth Below Grade:
County: GASTON Township:
Description Qty Unit Price Ext Price
Pumping 1 250.0000 $250.00
Subtotal $250.00
Tax $0.00
Total $250.00
Disposal Permit:SDTF36-04 Pumping Permit:NCS01373 Plumbing Permit:32828 Location Details
Tank bservations: We suggest these 3 keys to keep your system healthy Payment Detail
�S stem Operating Fine 1)Regular Servicing Type: Visa
Y P 9 2)Use K-zyme Bactena Additive
Waste Code: 3)Use a niter Card#: XXXXXXXXXX5924
Waste Consistency [A/Excessive Solids [ ] Heavy Sludge Exp.Date: 03/2019
Disposal Point: / � /4.f,'#;4 c PO Number: none
Disposal Volume: Gals Tons/CY
pH: Prior to Loading: Lab Terms: Due on Receipt
Inlet Baffle Outlet Baffle Backflushes Runback Tank Level
Truck: 19 Shop to Shop Break [ ]
Tech Initials: OnSite .j. $3 Break [ ]
Tech Name: Thai Puih Sales Rep: No Rep
CSR: Monica Ballard
n14,1100 = _ Customer Signature
Tech Notes `v tQ - We Sethi. 4-w�1L • C[E�•rEJ 1 -c o Pc>.N�
jitcYtit: S;21vmer,z iNe.c.15 ib CO;Iiboi c..Ml aeczed i tni.4- 'e stanley
environmental
Stanley Environmental (877)-263-8186 solutions
Remit Payment to: 131 Mariposa Rd, Stanley, NC 28164